Quoos, Anne NEW YORK STATE DEPARTMENT OF HEALTH,.. ' 6Z,
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Anne Berry _ Quoos Female
Date of Death Age If Veteran of U.S. Armed Forces,
10/21 /2018 80 yrs. War or Dates No
Place of Death Town of Hospital, Institution or
Z City, Town or Village Crown Point _ Street Address 6 Berry Patch Lane
Manner of Death 0 Natural Cause El Accident U Homicide Suicide El Undetermined ri Pending
EU Circumstances Investigation
Medical Certifier Name Title
Kathleen P . Huestis M.D.
Address
102 Racetrack Road, Ticonderoga, New York 12883
Death Certificate Filed Town of District Number Register Number
City, Town or Village T i conde roga 1 551
n❑Burial Date Cemetery or Crematory
❑E_ntombment— 1 0/24/201 8 Pine View Crematory
Address
fl remation Queensbury, New York
Date Place Removed
Z n Removal and/or Held
9. and/or Address
F_- Hold
U?
Q Date Point of
d Transportation Shipment
0 by Common Destination
Carrier
Li DisintermentDate Cemetery Address
• n Reinterment Date Cemetery Address
• Permit Issued to Registration Number
Name of Funeral Home Wilcox & Regan funeral home 01 821
Address
11 Algonkin St. , Ticonderoga, New York 12883
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
` Permission is hereby granted to dispose of the human re If ns es ribe bo e a is ed.
Date Issued 1 0/2 4/2 01 8 Registrar of Vital Stat
(signature)
District Number ` -5 t Place ,� v 12 4,c, /60 n •
f_
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
41 Date of Disposition W0/l I)g Place of Disposition ,,��� (4.;to,"
2 (address)
U
(section) (lot n her)` (grave number)
n• Name of Sexton or Person in Charge of Premises
/ (please pri t)
1.14
Signature ! <�6__ Title
(over)
DOH-1555 (02/2004)