St. Andrews, Susan NEW YORK STATE DEPARTMENT OF HEALTH - /SL
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Susan Ann St. Andrews Female
Date of Death Age If Veteran of U.S. Armed Forces,
02/19/2017 64 yrs. War or Dates No
}- Place of Death Town of Hospital, Institution or
.. City, Town or Village Ticonderoga Street Address 836 NYS Rte. 9N
a Manner of Death 0 Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
VCircumstances Investigation
W Medical Certifier Name Title
G Kathleen P. Huestis M.D.
Address
102 Race Track Road, Ticonderoga, NY 12883
ti Death Certificate Filed Town of District Number Register Number
City, Town or Village Ticonderoga 1 564 3
><`['Burial Date Cemetery or Crematory
02/22/2017 Pine View Crematory
„i;11 Entombment Address
[ Cremation Queensbury, New York
Date Place Removed
Z Removal and/or Held
2, ❑and/or
Address
CO
0 Date Point of
d` Transportation Shipment
0 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 11 Algonkin St. , Ticonderoga, New York 12883
iil Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
CC
t€Eu
Permission is hereby granted to dispose of the human rem ins describedri above as indicated.
Date Issued 2/2 0/2 01 7 ,Y
Registrar of Vital Statistics t �;motif / t cc-4 41,,e7l
(sigJature)
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:
ILI Date of Disposition Z 24 I n Place of Disposition e, ��,,,, e,'.y,,,,��(ct;oN,
I (address)
Lu
t
CC (section) (lot number) _ (grave number)
CI Name of Sexton or Person in Charge of Premises C .. r ,e4,4((T
AA (phase print)
ii Signature GA Title (AE MP&
(over)
DOH-1555 (02/2004)