Wood, Shirley NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit er It
Name First Middle - Last Sex
Shirley E. Wood Female
Date of Death Age If Veteran of U.S.Armed Forces, NO
I. August 14, 2013 `1C. War orrDates
Z Place of Death Hospital, Institution or
W City,Town, or Village Whitehall Street Address Home
0 Manner of Death ❑Natural Cause ❑Accident ❑Homicide Suicide ❑Undetermined ❑ Pending
W Circumstances Investigation
() Medical Certifier Name Title
W Robert W. Sponzo MD
0 Address
Cancer Center 102 Park Street Glens Falls New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Whitehall 5 7�� ti- O5 —I.?
❑Burial Date Cemetery or Crematory
August 16, 2013 Pineview Crematorium
❑Entombment Address
Cremation Quaker Road Queensbury, NY 12804
Date Place Removed
0 ❑Removal and/or Held
and/or Address
l' Hold
0 Date Point of
0 ❑Transportation Shipment
O. by Common Destination
0Carrier
0 Date Cemetery Address
0 ❑Disinterment
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Jillson Funeral Home, Inc. 00885
Address
46 Williams Street, Whitehall, New York 12887
~ Name of Funeral Firm Making Disposition or to Whom
2 Remains are Shipped, If Other than Above
X
W Address
0.
Permission is hereby granted to dispose of the human remains described above as indicated.Date Issued Off-Lc /3 Registrar of Vital Statistics �-c� W4 142i-v
(signature)
-DeZesh E.hi
District Number 'j"7 5 O , Place Wari-beiteri'1•New York
t- I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2
W Date of Disposition 08/16/2013 Place of Disposition Pineview Crematorium
2 (address)
U
uy
0
� (section) (I number)., ' � (grave number)
O Name of Sexton or Person in Charge of Premises ,st 1Hdi
2 (please rint) •
W
71-Signature Title :: MA-T pt7
(over)
DOH-1555 (02/2004)