Wilde,Malvina R NEW YORKSTATE DEPARTMENT OF HEALTH v ( 5`
Bureau of Vital Records �.� Burial - Transit Permit
Name First Middle Last Sex
Malvina R Wilde Female
Date of Death Age If Veteran of U.S.Armed Forces,
10/26/2022 69 Years War or Dates
H Place of Death Hospital,Institution or
Z City,Town or Village Queensbury Town Street Address 5 Shallow Creek Road,Queensbury Town,New York 12804
W Manner of Death g
G �Natural Cause Accident �Homicide Suicide Undetermined ❑Pendin
W Circumstances Investigation
W Medical Certifier Name Title
G Paul Filion MD
Address
3 Irongate Center,Glens Falls,New York 12801
Death Certificate Filed Town Of Queensbury District Number Register Number
City,Town or Village 5657 160
Burial Date Cemetery,Crematory or Facility Name
10/28/2022 Pine View Crematory Entombment —
Address
Cremation Queensbury Town,New York
Donation
z❑Removal Date Place Removed
and/or and/or Held
~ Hold Address
N
0
a, Date Point of
(I)aransportation Shipment
b by Common
Carrier Destination
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
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
f- Remains are Shipped,If Other than Above
`a Address
Q
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 10/28/2022 Registrar of Vital Statistics Caroline x&lfegarie Barber(ECectronicalty Signed)
(signature)
District Number 5657 Place Town Of Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition / -Z9-2�ZZ. Place of Disposition _,�P i/` et) C pepp/�^,.h
2 (address)
W
CC (section) (lot number) (grave number)
Name of Sexton or Person in Cha Premi s � C',�
,,-/IY/ 1 L iiDOc1
(please print/
W Signature 1 / Title 4")19-0-h-
DOH-1555(o7/18)p 1 of 2
C1636
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#