Wemmitt, Helen E . I It/
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Helen D. Wemmitt Female
Date of Death Age If Veteran of U.S. Armed Forces,
December 30, 2013 82 War or Dates
H Place of Death Hospital, Institution or
-= City, Town or Village Granville Street Address Orchard Nursing & Rehab Center
0'; Manner of Death n Natural Cause U Accident n Homicide Suicide Undetermined Pending
Circumstances Investigation
' Medical Certifier Name Title
ennl t' • es / 1I)
Address +'R
Death ificate Filed )Distr t Number Register Number
City, Tow "or Village Granville,NY Granville,NY 59
Jkp ,57)
❑Burial Date Cemetery or Crematory
January 2, 2014 Pine View Crematory
❑Entombment Address
El Cremation Queensbury, NY
Date Place Removed
Z Removal and/or Held
and/or Address
�' Hold
N
O Date Point of
NTransportation Shipment
p by Common Destination
Carrier
n Disinterment Date Cemetery Address
[i Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
t Remains are Shipped, If Other than Above
IAddress
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued (-R IS I POl3 Registrar of Vital Statistics ,-/ _
5 9 5` J/ (signature)
District Number Granville,Nflace Granville,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
tuDate of Disposition I /b I M Place of Disposition i Jv, 6, oriI—,
g (address)
W
Cl)
CL (section) (lot n`giber) (grave number)
pName of Sexton or Person in Charge of Premises hi /ir ,iMHli�
Z (please print)
wrj3---- Title CT uW'rTO'2
Signature 4L....
(over)
DOH-1555(02/2004)