Cross, Cecille r N a 3 SI—
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Cecille Cora Cross Female
Date of Death Age If Veteran of U.S. Armed Forces,
04/29/2018 92 yrs. War or Dates No
14 Place of Death Town o f Hospital, Institution or
City, Town or Village Ticonderoga Street Address 1 67 The Portage
j Manner of Death Q Natural Cause El Accident 0 Homicide El Suicide El Undetermined ri Pending
is Circumstances Investigation
t Medical Certifier Name Title
Glen Chapman M.D.
Address
CO P.O. Box 29 , Ticonderoga, New York 12883
Death Certificate Filed Town o f District Number Register Number
City, Town or Village T iconderoga 1 5 6 4 1 8
+?[]Burial Date Cemetery or Crematory
05/02/2018 Pine View Crematory
❑Entombment Address
Cremation Queensbury, New York
Date ' Place Removed
3 El Removal and/or Held
and/or Address
t7 Hold
0
0 Date Point of
tt Q Transportation Shipment
a by Common Destination
Carrier
�]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 Agonkin St. , Ticonderoga, New York 12883
Name of Funeral Firm Making Disposition or to Whom
14 Remains are Shipped, If Other than Above
I Address
•
Al
"" Permission is hereby granted to dispose of the human re 'ns descri ed abo e as indicated.
Date Issued 5/1 /201 8 Registrar of Vital Statistics L L
(signatu
ft District Number Isere.) Place //ancrajc t /V�� Y0 r K
J
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition c/ lig Place of Disposition ,.��,,,,,
ifi.___
a (address)
If
(section) !�^of numbe (grave number)10
Name of Sexton or Person in Charge of Premises ✓+44
2-- (p/ ase print)
Signature Title Afogifta
(over)
DOH-1555 (02/2004)