Condit, Cynthia NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Cynthia B. Condit _ Female
Date of Death Age If Veteran of U.S.Armed Forces,
12/02/2018 60 yrs. War or Dates No
Place of Death Town of Hospital, Institution or
City, Town or Village Putnam Station Street Address 1 54 2 Mosswood Way
Manner of Death Natural Cause ❑Accident D Homicide Q Suicide 0 Undetermined ❑Pending
l Circumstances Investigation
W Medical Certifier Name Title
0 Glen Chapman M_D_
Address
P.O. Box 29, Ticonderoga, New York 12883
Death Certificate Filed Town of District Number Register lumber
City, Town or Village Putnam Statcon 5763 `f
OBurial Date Cemetery or Crematory
12/6/2018 Pine View Crematory
❑Entombment Address
Cremation Queensbury, New York
Date Place Removed
Removal and/or Held
and/or Address
Hold
0 Date Point of
t.0 Transportation Shipment
by Common Destination
Carrier
0 Disinterment Date Cemetery Address
Li
Reinterment Date Cemetery Address
i
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 ..
w
a* Permission is hereby granted to dispose of the hum ins d ribed above as indicated.
Date Issued 1 2/5/2 018 Registrar of Vital Statistics
(sr nature)
District Number 5763 Place Town of Putnam Station
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition it I i li t Place of Disposition fa, �r►reri—P.1
(address)
eh
(section) (lot number) ( (grave number)
Name of Sexton or Person in Charge of Premises r r; ,r- )t,lttf'
z (pre print)
Signature ' Title fFr V(
(over)
DOH-1555 (02/2004)