Glading, Alice NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name FirsIlice Middle F. LGlading Sex Female
Date of Death Age If Veteran of.U.S. Armed Forces,
09/20/2015 90 years War or Dates
1- Place of Death Hospital, Institution or
,Ci Ti(dtd(?Sr sow Glens Falls Street Address Park St Glens Falls N Y
0 Manner of DeathLL1 Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
W Circumstances Investigation
L Medical Certifier Name Title
CZ Daniel Way M. D.
Address Park Street Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
Ci _TXr VAIffeX Glens Falls 5601 467
Burial Date Cemetery or Crematory
09/22/2015 Pine View Crematory
0 Entombment Address
E Cremation Queensbury, NY
Date Place Removed
Z n Removal and/or Held
gand/or Address
iii Hold
O Date Point of
fhEl Transportation Shipment
O by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Wilcox& Regan Funeral Home 01821
Address
11 Algonkin Street Ticonderoga, N Y
• Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
• Address
t
WA
• Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 09/22/2015 Registrar of Vital Statistics .) c.A..v —2.
(signature)
District Number 5601 Place Glens Falls / N / g-i/
" I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
�I 'ff
ill• Date of Disposition 91131 tc Place of Disposition 7 (1, `/
0.41 IA-.
2 (address)
Ili
tfl
CC (section) /i (lot number) (grave number)
• Name of Sexton or Person in Charge of Premises 4:71..-- -Cr•"ret
2 (please print)
Lti 4
,„„„„,„ Signature .4„ Title l *Mit
(over)
DOH-1555 (02/2004) ,