Woodcock, Mary NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name First Middle Last Sex
WOODCOCK MARY FEMALE
: ...... . ...... .
.. ..................
Date of Death Age if Veteran of U.S. Armed Forces,
12/15/94 93 War or Dates n/a
.......................... ...
Z Place of Death Hospital Institution or Maplewood Manor
W City Town or Village Ballston Spa Street Address Ballston Ave Ballston Spa
w Manner of Death f7l Natural Cause Accident ❑Homicide El Suicide Undetermined ❑ Pending
tai „Circumstances Investigation
.. .... _. ..:::_:.... . .:::.::. .. .. .. .. ....._..
.61 Medical Certifier Name Title
L. Gelman M.D.
.... . .
Address
128 Milton Ave. , Ballston Spa, N.Y. 12020
Death Certificate Filed District Number Register Number
<' City,Town or Village Ballston Spa 4520 p112
Date Cemetery or Crematory
❑Burial 12/16/94 Pineview Crematorium
.... _.:. _........ ....... ......._.. .. .. ...... .....
E3Cremation Address
Queensbury, N.Y.
Z Date Place Removed
O, [] Removal and/or Held
F- and/or Hold ...:.. . :::::::. .. ....... .,:.:
Address
0.....
rl Date ..... Point of
cn'; Transportation by
'p Common Carrier . ... - Shipment
Destination
.. .. .:..:......:....::.
Disinterment
Date Cemetery Address
El
..... . .......
Reinterment
Date Cemetery Address ..... ._.... ...... :: ::.
Permit Issued to Registration Number
Name of Funeral Firm Dnesmore Funeral Home, Inc. 00525
Address -
7 Sherman Ave. , Corinth, N.Y. 12822
4. Name of Funeral Firm Making Disposition or to Whom
s;': Remains are Shipped, If Other than Above
W
Address
d
Permission is hereby granted to dispose of the u an remains described above as indicated.
Deputy
Date Issued 12/16/94 Registrar of Vital Statistic
(signature)
District Number 4520 Place Ballston Spa, N.Y.
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
F-
Z; Date of Disposition r
W p �� - Place of Disposition � ,� ,i/;;rl) �'`'1�.�/1? �D�o`r/�l
2 (address)
W
Cn
CC (section) (lot number) (grave number)
p Name of Sexton or Person in harge of Premise i
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Z �e� ��L.- please print) t .
W` Signature Title 1' s��Y /
DOH-1555 (10/89) p. 1 of 2 VS-61