MacAlpine, Phyllis NEW YORK STATE DEPARTMENT OF HEALTH
3g/
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Phyllis MacAlpine Female
Date of Death Age If Veteran of U.S. Armed Forces,
05/09/2015 87 yrs. War or Dates No
f- Place of Death Town of Hospital, Institution or
ZCity, Town or Village Ticonderoga Street Address 607 Baldwin Road
0 Manner of Death 6 Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Ili Circumstances Investigation
al Medical Certifier Name Title
Kathleen P. Huestis M.D.
Address
102 Race Track Road, Ticonderoga, NY 12883
Death Certificate Filed Town of District Number Register Number
City, Town or Village Ticonderoga 1 564 28
OBurial Date Cemetery or Crematory
['Entombment 05/13/2015 Pine View Crematory
Address
®Cremation Queensbury, New York
Date Place Removed
Z ri❑Removal and/or Held
14— and/or Address
F= Hold
U)
0 Date Point of
in:Q`El Transportation Shipment
a by Common Destination
Carrier
❑Disinterment ' Date Cemetery Address
El Reinterment Date Cemetery Address
h. Permit Issued to Registration Number
Name of Funeral Home Wilcox & Regan funeral home 01 821
Address
11 Algonkin St. , Ticonderoga, NY 12883
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
M.
lL
it
` Permission is hereby granted to dispose of the human rem i described al
ov, . i dicated.
Date Issued 0 5/1 2/201 5 Registrar of Vital Statistics '
(s
District Number 1 564 Place Town of Tic-onderoga
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
1,1
ILI Date of Disposition 5/pile Place of Disposition e ,,, fog
2 (a dress)
III
ta
Cc (section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises `4i+ i)w�T
Z
( lease print)
ta
Signature t- Title /t747441 1/1.
(over)
')OH-1555 (02/2004)