Cossey, Vivian r 1
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permi
Name First Middle Last Sex
Vivian H.. CnssPy Female
igiii Date of Death Age If Veteran of U.S. Armed Forces,
08/09/P017 89 yrs_ War or Dates No
14 Place of Death Town of Hospital, Institution or Heritage Commons
City, Town or Village TiconderogaIti Street Address RPsidntial .Health Care
Manner of Death 0 Natural Cause _Accident _Homicide _Suicide Q Undetermined El Pending
tti Circumstances Investigation
to Medical Certifier Name Title
O. Robert J. Orr III M.D.
Address
102 Race Track Road, Ticonderoga, New York 12883
Death Certificate Filed Town of District Number Register umber
giiii g
a cf
City, Town or Village mi cnndero a 1 964
_Burial Date Cemetery or Crematory
08/10/2017 Pine View Crematory
_Entombment Address
;'`;Cremation Oueensbury, New York
Date Place Removed
{ ❑Removal and/or Held
and/or
Address
Et Hold
0_
Date Point of
Q Transportation Shipment
0 by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Wilcox & Regan funeral home 01 821
Address
ggi 11 Algonkin St. , Ticonderoga, New York 12883
Name of Funeral Firm Making Disposition or to Whom
14 Remains are Shipped, If Other than Above
2 Address
>t
ILI-
Pt Permission is hereby granted to dispose of the human rema" described ove ; indicated.
Date Issued 8/1 0/2 01 7 Registrar of Vital Statistics { -c'� alIN.
(signs .)
District Number 1 564 Place Town of Ticonderoga
.:::.>: I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k
in Date of Disposition f j jg/17 Place of Disposition ctik... atoro ..
(address)
Ili
WE
(section) number) (grave number)
Ci Name of Sexton or Person in Charge of Pr ises ((lot
,,14e9t r t.v1
tr
2 (ple¢se print)
;: Signature a » Title tt-1i R i_
(over)
DOH-1555 (02/2004)