Wood, Natalie NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit 13?
Name First Middle Last Sex
Natalie L. Wood Female
Date of Death Age If Veteran of U.S.Armed Forces, No
F June 10, 2015 77 War or Dates
Z Place of Death Hospital, Institution or
W City,Town,or Village Glens Falls Street Address Glens Falls Hospital
G Manner of Death El Natural Cause 1111 Accident 111 Homicide 0 Suicide ❑Undetermined ❑ Pending
W Circumstances Investigation
0 Medical Certifier Name Title MD
W Mathew Varughese
0 Address
102 Park Street Glens Glens Falls, NY 12801
Death Certificate Filed District Number y,,/� Register Number
City,Town or Village Glens Falls F 1
❑Burial Date Cemetery or Crematory
June 12, 2015 Pine View Crematory
❑Entombment Address
Cremation Quaker Road Queensbury, NY 12804—
Date Place Removed
0 El Removal and/or Held
i. and/or Address
le Hold
0 Date Point of
0 El Transportation Shipment
Da by Common Destination
Carrier
Date Cemetery Address
a El
Disinterment
Ej
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Jillson Funeral Home, Inc. 00885
Address
46 Williams Street, Whitehall, New York 12887
• ~ Name of Funeral Firm Making Disposition or to Whom
IX
Remains are Shipped, If Other than Above
W Address
a
Permission is hereby granted to dispose of the human remains describe above aA ind' d.
Date Issued (2d//2/20/' Registrar of Vital Statistics � z
(signature)
District Number J CC/ Place Glens Falls,New York
• I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition 06/12/2015 Place of Disposition Pine View Crematory
2 (address)
III
V)
0 (section) t number) (grave number)
00 Name of Sexton or Person in Charge of Premises . 4r,, �L it...At
Z (ple�se print)
ILI
Signature 1 4 Title 1116411 P'I
•
(over)
DOH-1555 (02/2004)