Wendell, Carmen NEW YORK STATE DEPARTMENT OF HEALTH Allot '! '•
Vital Records Section Burial - Transit Permit
• Name First Middle Last Sex
Carmen L. Wendell Female
Date of Death Age If Veteran of U.S. Armed Forces,
January 11, 2015 57 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death El Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
Medical Certifier Name Title
Aqeel A. Gillani, M.D. Dr.
Address
102 Park Street Glens Falls, NY 12801
Death Certificate Filed District Number 0I Regi r`Number
City, Town or Village Glens Falls fq l
❑Burial Date Cemetery or Crematory
�# January 13, 2015 Pine View Crematory
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment
by Common Destination
. Carrier
wDate Cemetery Address
❑ Disinterment
ElReinterment Date Cemetery Address
g Permit Issued to Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home 01078
Address
It 136 Main Street, South Glens Falls NY 12803
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human re ains de cribed abov assiinndica ed.
• Date Issued O 1 i / ' Registrar of Vital Statistics �C?� �i'71 p'?"- -
/ (sign Lure)
District Number,3-' / Place ,� 1a
I certify that the remains of the decedent identified above wer disposed of in accordance wit this permit on:
Date of Disposition 01/13/2015 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) (I t number) (grave number)
Name of Sexton or Person in Charge of Premises A hp sc..dir
(plea a print)
6&Ajzr___▪ SignatureTitle (PrimtfilM
(over)
DOH-1555 (02/2004)