Wilson, Nancy A-13.
y
NEW YORK STATE DEPARTMENT OF HEALTH ell Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Nancy Wilson
Female
Date of Death Age If Veteran of U.S.Armed Forces,
02/09/2022 84 Years War or Dates
i_ Place of Death Hospital,Institution or
WCity,Town or Village Glens Falls Street Address Glens Falls Hospital
p Manner of Death 0 Natural Cause 1=1 Accident ❑Homicide Suicide 0 Undetermined 0 Pending
W Circumstances Investigation
V MIMedical Certifier Name Title
CI Shahid Ahmed MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 96
0 Burial Date Cemetery,Crematory or Facility Name
02/11/2022 Pine View Crematory
0 Entombment Address
X❑Cremation Queensbury Town,New York
Donation
Date Place Removed
ElRemoval and/or Held
F and/or
N
Hold Address
0
Date Point of
(I) 0 Transportation Shipment
Q by Common
Carrier Destination
Date Cemetery Address
ElDisinterment
Date Cemetery Address
❑Reinterment
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
1— Remains are Shipped,If Other than Above
2 Address
Q
WI
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 02/11/2022 Registrar of Vital Statistics Megan Yolin(ElectronicalySigned)
(signature/
District Number 5601 Place Glens Falls, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:W Date of Disposition o?�a ZDZ�Place of Disposition }�;,.J 2 �� ecc) C~(�ti �`'
2 address)
IW
Cl) (section), (lot number) (grave number)
0 Name of Sexton or Person in Cha f Premises i /MP'Jcl ✓"ODD
Q (please print)
W Signature Title ( —w""
DOH-1555(o7/18)p t of 2 U
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg. or License#