Wheeler, Mary NEW YORK STATE DEPARTMENT OF HEALTH A 0(3
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Mary Adelaide Wheeler Female
Date of Death Age If Veteran of U.S.Armed Forces,
September 29, 2014 61 War or Dates No
(— Place of Death Hospital, Institution
Z City,Town or Village City of Albany or Street Address Albany Medical Center
G Manner of Death Natural El
❑ Pending
W ® Cause ❑ Accident ❑ Homicide ❑ Suicide
Circumstances Investigation
W; Medical Certifier Name Title
o Gregory Wu MD
Address
43 New Scotland Ave., Albany, NY 12208
Death Certificate Filed District Number Register Number
City,Town or Village City of Albany 101 1822
Date Cemetery or Crematory
❑ Burial October 1, 2014 Pine View Crematory
❑ Entombment Address
® Cremation Queensbury, NY
Date Place Removed
Z Removal and/or Held
0 ❑ and/or Address
H Hold
Cl,
0 Date Point of
Q. Transportation Shipment
co" ❑ By Common p
CI Carrier Destination
❑ Disinterment Date Cemetery Address
❑ Date Cemetery Address
Reinterment
Permit Issued To Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home 01079
Address
82 Broadway, Fort Edward, NY
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
�' Address
W
a Permission is hereby granted to dispose of the human remains described a ve as Indicated
Date September 30, 2014 Registrar of Vital Statistics z ' i �/ P��
Issued g (sign ure)�✓� / f
District Number 101 Place City of Albany, NY
I certify that the remains of`the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition 10/l[ly Place of Disposition �►i1)u�.t' er ar,,.�
L (address)
w
CO
re (section) (lot number) (grave number)
0
o SAName of Sexton or Person in Charge of Premises tstifi,_
11.1 (please print) '���"",��
Signature — Title ►f1.M
(over)
DOH-1555 (02/2004)