Wilson, Arthur NEW YORK STATE DEPARTMENT OF HEALTH 4 9 6
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Arthur John Wilson Male
Date of Death Age If Veteran of U.S. Armed Forces,
01/15/2012 87 years War or Dates ww II
j- Place of Death Hospital, Institution or
City, TowR 1(ili x riens Falls Street Address glens Falls Hnspital
i0 Manner of Death❑Nptural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
t✓f Circumstances Investigation
tu Medical Certifier Name Title
fl Mathew Varughesa MD
Address
100 Park Street Glens Falls, Ny 12801
Death Certificate Filed District Number Register Number
City, Tow (ilLARXX Glens Falls 5601 26
RII❑Burial Date Cemetery or Crematory
❑Entombment 01/17/2012 Pine View Crematorium
0. Address
•
❑C,yemation ' Queensbury, NY 12804
Date Place Removed
3❑Removal and/or Held
and/or Address
F= Hold
0 Date Point of
ti❑Transportation Shipment
L by Common Destination
hi Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D. Baker Funeral Home 01130
Address
11 Lafayette Street Queensbury, N Y 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
;; Address
2
t
IL
Permission is hereby granted to dispose of the human remains described above as indicated.
ini Date Issued 01/17/2012 Registrar of Vital Statistics (, J W
v- `' (signature)
District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2
IL/ Date of Disposition 1/if it.Z Place of Disposition 1,4 U ,./ C f0 e;`
2 (address)
Ili
CA
CC (section) `, (lot numbe (grave number)
CI Name of Sexton or Pe on in Charge of Premises 71(,s l 10.1/
Q ,_. (please print)
IC!! Signature i tl .,L Title CE OD ION,
V
(over)
DOH-1555 (02/2004)