Wood, Faye NEW YORK STATE DEPARTMENT OF HEALTH , -i ril
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Faye D Wood Male
Date of Death Age If Veteran of U.S.Armed Forces, NO
F February 8, 2015 69 War or Dates
Z Place of Death Hospital, Institution or
W City,Town,or Village Clemons Street Address His home
0 Manner of Death ®Natural Cause ❑ Accident ❑Homicide ❑Suicide ❑Undetermined ❑ Pending
W Circumstances Investigation
U Medical Certifier Name Title
W Mrs. Ruth Scribner Coroner
Q Address
Whitehall, NY 12887
•
Death Certificate Filed District Number Register Number
City,Town or Village Clemons 577 5 :- O j
❑Burial Date Cemetery or Crematory
February 13, 2015
❑Entombment Address
z 0 Cremation ,
Date Place Removed
a ❑Removal and/or Held
- and/or Address
I' Hold
Date (Cr".of
a ❑Transportation + Snipment
ea by Common Destination
Carrier
Date Cemetery Address
a ❑Disinterment
❑ Renterment 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
ii Remains are Shipped, If Other than Above
W Address
O.
Permission is hereby granted to dispose of the human remains described abov as indicated.
Date Issued .2`//r/..5 Registrar of Vital Statistics 7144t.4.,C..,rtiit, f Li,614A--.
(signature)
District Number J 15 2-. Place Clemons,New York
F I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2 7
W ,Date of Disposition 02/13/2015 Place of Disposition t 4., (i -&r' .
2 (address)
W
lb
0 0 (section) (lot nuer)- (grave number)
rr Name of Sexton or Person in Charge of Premises r,� L
lU (please prim
Signature (/� .� Title Ht?It.
(over)
DOH-1555 (02/2004)