Spaulding, Simone H ' 701
•
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
0.- Name First Middle Last Sex
Simone H Spaulding Female
Date of Death Age If Veteran of U.S.Armed Forces,
03/01/2022 . 86 Years War or Dates
F- Place of Death Hospital,Institution or
Z City,Town or Village Wilton Town Street Address 5 Birchwood Drive,Wilton Town,New York 12866
Manner _Natural Cause DAccident Homicide ❑Suicide ❑Undetermined ❑Pending
W x
Circumstances Investigation
WMedical Certifier a Title
O Eugene Merecki MD
Address
6 Medical Park Drive,Malta Town,New York 12020
Death Certificate Filed Town of Wilton District Number Register Number
Cit ,Town or Village
g 4569 18
Burial Date Cemetery,Crematory or Facility Name
03/04/2022 Pineview Crematory
Entombment Address
Cremation Queensbury Town,New York
_Donation
— —
d❑Removal Date Place Removed
and/or and/or Held
NHold Address
0
O. Date Point of
U)❑Transportation Shipment
5 by Common
Carrier Destination
Disinterment
Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Densmore Funeral Home Inc 00448
Address
7 Sherman Ave,Corinth,New York 12822
Name of Funeral Firm Making Disposition or to Whom
F. Remains are Shipped,If Otherthan Above
Address
CC
W
g" Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 03/04/2022 Registrar of Vital Statistics SusanOalJviaiElctsnnrealZ .4pr4
(signature)
District Number 4569 Place Town Of Wilton
I certify thatthe remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition ....,5*-:.20,2g Place of Disposition et ,-J e ✓)e(,) (rA ,i4't(
W (address)
W
it (section) J-(l�number/ (glare number)
8 Name of Sexton or Person in Cha of Pr mi s >� ! �'d VvLD c
Z (please print)
ILI
Signature 7/1/ l Title Ore' 'c•4r,C
DOH-1555(07/18)p i of 2
48
Public Health Law Sec. 4145(2b) 1 }�Q1
Receipt
Human remains of delivered on , 20.
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#