Wilson, Lynn O NEW YORK STATE DEPARTMENT OF HEALTH / Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Lynn 0 Wilson Female
Date of Death Age If Veteran of U.S.Armed Forces,
11/28/2022 78 Years War or Dates
F— Place of Death Hospital,Institution or
WCity,Town or Village Fort Ann Town Street Address 3601 Echo Bay Lane, Fort Ann Town, New York 12827
p Manner of Death ❑X Natural Cause []Accident ❑Homicide Suicide Undetermined Pending
W U Circumstances Investigation
W Medical Certifier Name Title
G Darci Gaiotti-Grubbs MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed Town Of Fort Ann District Number Register Number
City,Town or Village 5754 25
Burial Date Cemetery,Crematory or Facility Name
11/30/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
o Removal Date Place Removed
and/or and/or Held
H Hold Address
N
0
0. Date Point of
U)ETransportation Shipment
Q by Common
Carrier Destination
O
Disinterment
Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Homf 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
CC
W
n' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11/30/2022 Registrar of Vital Statistics ,7ennifer,7ackson(Electronicall:y Stgne4
(signature)
District Number 5754 Place Town Of Fort Ann
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I— - , 1
WDate of Disposition 12 I'2 L i L Place of Disposition 4uti— /-4��
2 (address)
W
Q (section) (16. (it number).. on' i�f (grave number)
SName of Sexton or Person in Charge of Premis
z
(pl se print) 7�'
W Signature Title CfF q 1"
DOH-1555(07/18)pi of 2
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
1
1
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#