Wilk, Barbara NEW YORK STATE DEPARTMENT OF HEALTH $
Vital Records Section Burial - Transit Permit
. Name First Middle Last 1 Sex
Barbara T. Wilk Female
Date of Death Age ! If Veteran of U.S. Armed Forces,
January 11, 2012 72 ' War or Dates
Place of Death Hospital, Institution or
Z City, Town or Village Glens Falls, NY Street Address Glens Falls Hospital
00, Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
US Circumstances Investigation
s Medical Certifier Name Title
P. Mark Hoffman,MD
Address
Glens Falls,NY 12801
Death Certificate Filed District Number I Register NuAsber
City, Town or Village Glens Falls,NY 5601
❑Burial Date Cemetery or Crematory
January 13,2012 Pine View Crematory
❑Entombment Address
El Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z I I Removal and/or Held
and/or Address
H Hold
N
O Date Point of
O.
I I Transportation Shipment
'p by Common Destination
Carrier
I I Disinterment
Date ( Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton-Healy Funeral Home 1 01596
Address
407 Bay Road,Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
I Remains are Shipped, If Other than Above
', Address
rd
Atf
Permission i h reby granted to dispose of the human r ains described ab• e as indica =d.
Date Issued p/ /� „7D/�, Registrar of Vital Statistics /t _ .�l'- 'A ,.I.,.'
(signature
District Number 5601 Place Glens Falls,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I—
W Date of Disposition (/13)17, Place of Disposition g m U u.j Crt"ctof tut.,
2 (address)
lL
Cl)
CZ (section) 4(: *trbr. (lot�ber) (grave number)
Q Name of Sexton or Perso 'n Charge of remises evv►PttZ (please print)
W Signature Title a E rA 11-tr. —
(over)
DOH-1555(02/2004)