Wilson, Marjorie NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name First Middle Last Sex
orie D. Wilson Female
Date of Death Age If Veteran of U.S. Armed Forces,
War or Dates
Place of Death Hospital, Institution or
or Village Hartfora Street Address
::::::::Manner of Death Undetermined Pending
Natural Causes❑Accident ❑ Homicide ❑ Suicide ❑ Circumstances ❑ Investigation
Medical Certifier Name Title
Michael CaSt--rn MD
Address
100 Park St
Death Certificate Filed District Number Register Number
for Village Hartford
❑ Burial ate Cemetery or Crematory
June 22, 1999 Pine View Crematorium
X❑ Cremation Address
Th of Queensbury, NY 12804
Date Place Removed
❑ Removal and/or held
and/or hold Address
Date Point of
❑ Transportation by Shipment
Common Carrier
Destination
Date Cemetery Address
ElDisinterment
❑ Reinterment Date Cemetery Address
::::,:::::Permit issued to Registration Number
Name of Funeral Firm Carleton Funeral Home Inc. 00313
Address
P.O. Box 67, 68 Main St., Hudson Falls, N.Y. 12839
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is he eby granted to dispose of the human remains descQj ab ve as indicated.
Date Issue Registrar of Vital Statistics
S natu e)
District Number Place Hartford, Y
N
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Dispositio�Place of Disposition ���' !�� 1
(address)
(Section) (Lot Number) (Grave Number)
Name of Sextoyj or Person in Charge o Premises e7ak-4/ 4
(Please Print)
Signature Title Q
DOH-1555 (10/89) p. 1 of 2 VS-61