Wilson, Ashley NEW YORK STATE DEPARTMENT OF HEALTH ` 1
Vital Records Section Burial - Transi Pe mit
Name First Middle Last Sex
Ashley Wilson Female
Date of Death Age If Veteran of U.S. Armed Forces,
June 16,2013 30 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
8 Manner of Death Natural Cause n Accident n Homicide —_ Suicide n Undetermined n Pending
Circumstances Investigation
Medical Certifier Name Title
a Michael Sikirica MD
Address
Waterford,NY
Death Certificate Filed District Number Register Num
, City, Town or Village c
Y 9 Glens Falls 5601
❑Burial Date Cemetery or Crematory
❑Entombment June 18, 2013 Pine View Crematorium
Address
El Cremation 21 Quaker Road,Queensbury,NY 12804
Date Place Removed
Z
I I Removal and/or Held
and/or Address
H Hold
N
O Date Point of
5 n Transportation Shipment
a by Common Destination
Carrier
n Disinterment Date Cemetery Address
pi Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
a Address
53 Quaker Road, Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
tr: Remains are Shipped, If Other than Above
Address
,w:
Permission is hereby granted to dispose of the human remains d cribed ab e as indicat d.
Date Issued 0/4/C7//p6 Registrar of Vital Statistics -e �'�si nature , /k.�
1 g ����
District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z C'
� Date of Disposition (�{+�I�� Place of Disposition r nweFr>,•1r--
2 (address)
co
(Y (section) "lot number) r (grave number)
Op Name of Sexton or Person in Charge of Premises As br t��tt
W ( ease print)
I/
Signature
7j . Title CQifP►14 GdID
(over)
DOH-1555(02/2004)