Wilder, Joan NEW YORK STATE DEPARTMENT OF HEALTH { br
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Joan E. Wilder Female
Date of Death Age If Veteran of U.S. Armed Forces,
December 8, 2012 81 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Queensbury Street Address 21 Oakwood Drive
0 Manner of Death X Natural Cause n Accident Homicide Suicide n Undetermined Pending
tit Circumstances Investigation
Kt Medical Certifier Name Title
Dara Gaiotti-grubbs,MD
Address
102 Park Street,Queensbury,NY 12804
a�°' Death Certificate Filed Diatil4t Number Rp9isterNumber
City, Town or Village Queensbury (D'S—) I' `0
❑Burial Date Cemetery or Crematory
December 11,2012 Pine View Crematorium
❑Entombment Address
❑x Cremation 21 Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
F' Hold
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0 Date Point of
NTransportation Shipment
6 by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
y_: Name of Funeral Home Regan& Denny Stafford Funeral Home 01443
Address
53 Quaker Road, Queensbury,NY 12804
y Name of Funeral Firm Making Disposition or to Whom
14 Remains are Shipped, If Other than Above
3 Address
.I .
US
Et. Permission is here y granted to dispose of the human re ins described ab ve as indicated.
q .
Date Issued�1 h 0�0 ICE, Registrar of Vital Statistics �C�12.t1C�PV.-._- ____
(signature)
District Number+S(cn Place Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z W Date of Disposition I�-(3-l't Place of Disposition ZU
�G� a ft•—
W (address)
Cl)
0 (section) Li (lot number) (grave number)
pName of Sexton or Person in Charge of Premises `�
Z please print)
W Signature i4La.._ Title CaW't 16L
tg (over)
DOH-1555(02/2004)