Wilson, Burke NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Burke Chappell Wilson Female
Date of Death Age If Veteran of U.S. Armed Forces,
Mi 07/13/2017 80 yrs. War or Dates No
i4., Place of Death Town of Hospital, Institution or
7930 Lake Shore Drive
13 City, Town or Village
Hague Street Address
Manner of Death g � Silver Bay
ILI
X Natural Cause Accident El Homicide El Suicide 0 Undetermined ri Pending
0Circumstances Investigation
tii Medical Certifier Name Title
K.P. Huestis M.D.
Address
P.O. Box 29, Ticonderoga, New York 12883
Death Certificate Filed Town of District Number Register Number
g. City, Town or Village Hague 5653 7
ig El Burial Date Cemetery or Crematory
QEntombment 07/17/2017 Pine View Crematory
Address
`? ®Cremation Queensbury, New York
Date Place Removed
Removal and/or Held
and/or Address
ti.i= Hold
id Date Point of
aEl 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 Algonkin St. , Ticonderoga, New York 12883
iq Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
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!" Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 17-/6-clb/']Registrar of Vital Statistics Ix/IL?' l. jla _
(signature)
District Number�706-3 Place -To con o4-
(-MI6(.1,t,l 4
I
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2
III Date of Disposition i 11S 1 l Place of Disposition f FAA, C 0(3.--
(address)
1I
40.
CC (section) (lot number) (grave number)
ct Name of Sexton or Person in Charge of P emises ar� � St lit
1 (ple a print)
L Signature Q Title (WM N-
(over)
DOH-1555 (02/2004)