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Drake, Claire OR # 113 NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit >' Name First Middle Last Sex Claire Veronica Drake Female Date of Death Age If Veteran of U.S. Armed Forces, Mi 09/1 7/2 017 67 r s. War or Dates No 14 Place of Death Town of Hospital, Institution or it City, Town or Village Ticonyip,rrITa Street Address 41 Grace. Avenue a Manner of Death©Natural Cause 0 Accident 0 Homicide OSuicide riUndetermined 0 Pending US Circumstances Investigation til Medical Certifier Name Title gi Herbert Savel M.D. Address P.O. Box 67, Elizabethtown, NY 12932 : Death Certificate Filed Town of District Number Register Number City, Town or Village Ticonderoga 1 564 34 iiii ❑Burial Date Cemetery or Crematory ['Entombment Pine View Crematory Address ®Cremation Queens bury, New York Date Place Removed Removal and/or Held and/or Address tt Hold tf3 Date Point of ft Q Transportation Shipment by Common Destination - Carrier Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number m. Name of Funeral Home Wilcox & Regan funeral home 01 821 eiii Address 11 Algonkin St. , Ticonderoga, New York 12883 Name of Funeral Firm Making Disposition or to Whom }- Remains are Shipped, If Other than Above • Address te Permission is hereby granted to dispose of the human re ins described above as indicated. Date Issued 9/2 0/2 01 7 Registrar of Vital Statistics /� / crLvj 1. U (sign re District Number 1 564 Place: iE Town of Ticonderoga I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: k ILI Date of Disposition 9/2i2(O Place of Disposition f'J ./ C4-r-j f or 10, (address) A ta CC (section) (lot number) a (grave number) flName of Sexton or Person in Charge of P mises ��"i i jAv.41 2 (p/e se print) fii SignatureP e— Title ift Oft(1n- (over) DOH-1555 (02/2004)