Thompson, Mary ti
s N. 11 3gr
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Mary Beth Thompson Female
Date of Death Age If Veteran of U.S. Armed Forces,
July 8, 2013 55 yrs. War or Dates No
Place of Death Town of Hospital, Institution or
Z City, Town or Village Ticonderoga Street Address 3 John Street
Manner of Death®Natural Cause ❑Accident ❑Homicide ❑Suicide ❑ Undetermined ❑Pending
JAI Circumstances Investigation
tgi Medical Certifier Na Title
,e/ c, k/i mL,e /�I 1.
�� s s( /( Asp. Ilt-A36 1((s, _/
Death Certificate Filed Town of District Number Register Number
City, Town or Village Ticonderoga 1 if 4
0 Burial Date Cemetery or Crematory
❑Entombment 07/10/2013 Pine View Crematory
Address
❑X Cremation Queensbury, New York
Date Place Removed
Z Removal and/or Held
❑and/or Address
-, Hold
Eli
o Date Point of
hEl Transportation Shipment
0 by Common Destination
Carrier
❑Disinterment Date Cemetery Address
N. ❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Ni 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
2 Address
rt
to
Permission is hereby granted to dispose of the human remai escribed bove a indicated.
k..! Date Issued 7/1 0/2 01 3 Registrar of Vital Statistics ,�
(s nature)
gi 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:
2
lit Date of Disposition 1-10-13 Place of Disposition gi 0kC*cf0 _...
2 (address)
ILI
is (section) lot numbeL (grave number)
c-
0 Name of Sexton or Pers n in Charge of remises i 1 �'^�+I
2► if(please print)
• Signature 1.-- Title Cnfllee,
(over)
DOH-1555 (02/2004)