Wood, Kathryn NEW YORK STATE DEPARTMENT OF HEALTH Z
Vital Records Section Burial - Transit ermit
Name First Middle Last Sex
Kathryn A. Wood Female
Date of Death Age If Veteran of U.S. Armed Forces,
May 26,2012 91 War or Dates
'g, Place of Death Hospital, Institution or
Z City, Town or Village Glens Falls Street Address Panes Of Glens Falls
di
Manner of Death n Natural Cause n Accident I I Homicide Suicide ❑Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Suzanne Rayeski DR.
Address
, 170 Warren Street,Glens Falls,NY 12801
" Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 'Z r-1 5
❑Burial I Date Cemetery or Crematory
El Entombment May 31,2012 Pine View Crematorium
Address
®Cremation 21 Quaker Road,Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
C and/or ' Address
F_ Hold
a
0 Date Point of
N ❑Transportation Shipment
3 by Common Destination
Carrier
n Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
Permit Issued to Registration Number
_: Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Road,Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
M. Remains are Shipped, If Other than Above
2 Address
te
M
f"` Permission is hereby granted to dispose of the human remains described above as,indicated.
Date Issued 5! 3 c)// Z Registrar of Vital Statistics LA CA. /r
(signature
District Number 5601 Place Glens Falls f T
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w Date of Disposition (O A y 112 Place of Disposition 4204o uw COW-40 rw._^
Ili (address)
CO
Ce
(section) n (lot nurser) (grave number)
Q
Name of Sexton or Person in Charg of Premises c Se,,,tt
Z V (please print)
W SignatureAL_
Title Ck rrp too.
(over)
DOH-1555(02/2004)