Croto, Dona it 14
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Dona N. Croto Female
Date of Death Age If Veteran of U.S.Armed Forces,
7/30/2018 84 yrs. War or Dates No
1 Place of Death Town o f Hospital, Institution or
E. City, Town or Village Ticonderoga Street Address 1037 Wicker Street
Manner of Death 0 Natural Cause Accident Q Homicide Suicide Undetermined Pending
tip Circumstances Investigation
Medical Certifier Name Title
3 Glen Chapman M.D.
Address
P_n- Rnx 79, Ticoid?-r_o a, New York 12883
Death Certificate Filed Town o f Districf Number Register Number
: City, Town or Village Ticonderoga 1 56� 29
:1 OBurial Date Cemetery or Crematory
"[]Entombment V�/2/2ress01a Pi ne View_ crematory
Add
_` (iCremation Queensbury, New York
tte Place Removed
❑Removal and/or Held
:wok and/or Address
Lt Hold
i
fl Date Point of
ftQ Transportation Shipment
3 by Common Destination -
Carrier
Q Disinterment Date Cemetery Address
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
'„ Address
at
t ;
Permission is hereby granted to dispose of the human rema- describe above indicated.
Date Issued 8/2/2 01 8 Registrar of Vital Statistics �� f �c if�(signature)
District Number /S6,% Place crlct-P/` x40..._,,
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k
tti Date of Disposition 9 131 ty Place of Disposition $,
2 (address)
t (section) (lot n ynber) (grave number)
Name of Sexton or Person in Charge of Premises (iiir,� S t" 't
2 (please pn t)
Signature h Title
(over)
DOH-1555 (02/2004)