Wilson, Cynthia J NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Cynthia J Wilson Female
Date of Death Age If Veteran of U.S.Armed Forces,
11/21/2023 61 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village North Hudson Town Street Address 3920 US 9 Route,North Hudson Town, New York 12855
111
'p Manner of Death Natural Cause []Accident []Homicide aSuicide Undetermined Pending
U Circumstances Investigation
W Medical Certifier Name Title
CI Kellie Valentine Coroner
Address
PO Box 132,Elizabethtown Town,New York 12932
Death Certificate Filed Town Of North Hudson District Number Register Number
City,Town or Village 1561 02-23
Burial Date Cemetery,Crematory or Facility Name
11/25/2023 Pine View Crematory
Entombment Address
[]Cremation Queensbury Town,New York
Donation
O[]Removal Date Place Removed
and/or and/or Held
Hold Address
0
a- Date Point of
(1)❑Transportation
by Common Shipment
Carrier Destination
Date Cemetery Address
[]Disinterment
[]Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Edward L Kelly Funeral Home 00519
Address
PO Box 548,Schroon Lake,New York 12870
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped,If Other than Above
Address
CC
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11/22/2023 Registrar of Vital Statistics glaraa al. Ring(Electranicall Signed)
(signature)
District Number 1561 Place Town Of North Hudson
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
F- J
Z Date of Disposition //-Z5.Zol a Place of Disposition j}ti vl e f e L:r���►£'t L+
2 (address)
W
CC CC (section) (lot nuttier) i (grave number)
0 Name of Sexton or Person in Charge remiseses�`f !"'`
Z (please print)
W �� Title {,tit S
Signature
DOH-1555(07/18)a i of 2
.7692
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#