Windeknecht, Anne 7gc
NEW YORK STATE DEPARTMENT OF HEALTH 7
Vital Records Section - Burial - Transit Permit
Name First Middle Last Sex
Anne K. Windeknecht Female
Date of Death Age If Veteran of U.S. Armed Forces,
01 /1 5/2017 79 yrs. War or Dates No
1- Place of Death Town of Hospital, Institution or
; Herita
W City, Town or Village Ticonderoga Street Address Residentialommons Health Care
Manner of Death Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
In
Circumstances Investigation
tu Medical Certifier Name Title
Q Glen Chapman M.D.
Address
P.O. Box 29, Ticonderoga, New York 12883
Death Certificate Filed Town of District Number Register Number
City, Town or Village Ticonderoga 1 564 2
CI Burial Date Cemetery or Crematory
01 /17/2017 Pine View Cremator
El Entombment Address y
:: `®Cremation Queensbury, New York
Date Place Removed
Z Removal and/or Held
ga and/or
r , Address
Cl)
Hold
0 Date Point of
LL Transportation to ❑ p Shipment
0 by Common Destination
Carrier
El 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
rc
to
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 1 /1 7/2 01 7 Registrar of Vital Statistics Larx ))sc1�>
d (si ature)
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:
p Oil Cr7 p ( z.,. C rc
t Date of Disposition l Place of Disposition f, Krri f e•„
(address)
CC (section) (lot number) (grave number)
a
Name of Sexton or Person in Charge of Pr mises <' Se r 4 i
,e/ (pl ase print)'
Signature �..G i Title (
(over)
DOH-1555 (02/2004)