Wood, Glenn NEW YORK STATE DEPARTMENT OF HEALTH . p 1 S Z
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Glenn G Wood Male
Date of Death Age If Veteran of U.S.Armed Forces,
E. December 6, 2013 91 War or Dates
z Place of Death Hospital, Institution or
W City,Town,or Village Glens Falls Street Address Glens Falls Hospital
0 Manner of Death ❑Natural Cause ❑Accident ❑Homicide Suicide ❑ Undetermined ❑ Pending
W Circumstances Investigation
u Medical Certifier Name Title
W
0 Address
Death Certificate Filed District Number b �� RegiM��er
City,Town or Village Glens Falls
❑Burial Date Cemetery or Crematory
December 11, 2013 Pineview Crematorium
❑Entombment Address
m 0 Cremation Quaker Road Queensbury, NY 12804
Date Place Removed
0 ❑Removal and/or Held
- and/or Address
i" Hold
0 Date Point of
0 E Transportation Shipment
d by Common Destination
Carrier
Date Cemetery Address
O ❑ 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
a
Permission is hereby;anted to dispose of the human r ains d scribed a ve as indi,ated
Date Issued J j0 0iC3 Registrar of Vital Statistics � ` �� .
(signature)
District Number s. rGe) / Place Glens Falls,New ork
F I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition 12/11/2013 Place of Disposition Pineview Crematorium
W (address)
Ih
0 0 (section) lot number) (grave number)
Name of Sexton or Person' Charge of Premises ! iiga"IT KJ.
W ) (pldase print)
lr- i--
Signature Title
(over)
DOH-1555 (02/2004)