Rocque, Tara f
it
NEW YORK STATE DEPARTMENT OF HEALTH NEW
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Tara Michele Roc quip Female
Date of Death Age If Veteran of U.S. Armed Forces,
05/20/2018 44 yrs_ War or Dates No
iI Place of Death Town of Hospital, Institution or
IlitCity, Town or Village TicondPr�a Street Address 22 Al Pxandrja Aire_
Manner of Death 0 Natural Cause 0 Accident 0 Homicide El Suicide D Undetermined ri Pending
la
Circumstances Investigation
Ili Medical Certifier Name Title
C. Francis Varga M.D. _
Address
P.O. Box 768, Lake Placid, NY 12946
.. Death Certificate Filed Town of District Number Register Number
>' City, Town or Village T i onndArorja 1 5 6 4 ��
❑Burial Date Cemetery or Crematory
05/22/2018 Pine View Crematory
❑Entombment Address
'=':®Cremation Queensbury, New York
Date Place Removed
2. Removal and/or Held
❑and/or Address
f= Hold
44.
0 Date Point of
Q Transportation Shipment
la by Common Destination
giiii Carrier
El Disinterment Date Cemetery Address
mi.LiReinterment Date Cemetery Address
iMi Permit Issued to Registration Number
im Name of Funeral Home Wilcox & Regan funeral home 01 821
Address
iig 11 Algonkin St. , Ticonderoga, NY 12883
>` Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
1.1
Permission is hereby granted to dispose of the human rem - described ove s indicated.
Date Issued 05/21 /201 8 Registrar of Vital Statistics \\stypi- S-eAl\
(sig to )
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:
lI Date of Disposition 5.IZ1 f i' Place of Disposition
a (address)
al (section) 1q (lot number) (grave number)
ttName of Sexton or Person in Charge of Premises L�n, d >fr
/� (p ase print)
iiiilf Signature ! ✓'/ Title rooli 1i_
(over)
DOH-1555 (02/2004)