Pozzouli, Ailien NEW YORK STATE DEPARTMENT OF HEALTH < • -4O
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Ailien D. Pozzouli Female
Date of Death Age If Veteran of U.S. Armed Forces,
March 7, 2017 87 yrs, War or Dates No
Place of Death Hospital, Institution or
j City, Town or Villa e Tcon of Street Address 41 Park Avenue
Ili9 Ticonderoga
C) Manner of Death Eul771 Natural Cause El Accident 0 Homicide D Suicide El Undetermined Pending
tki Circumstances Investigation
ta Medical Certifier Name Title
41 C. Francis Varga M.D.
Address
P.O. Box 768, Lake Placid, NY 12946
Death Certificate Filed Town of District Number Register Number
Zil City, Town or Village Ticonderoga 1 564 6
❑Burial Date Cemetery or Crematory
QEntombment 3/13/2017 Pine View Crematory
Address
[Cremation Queensbury, New York
Date Place Removed
Z Removal and/or Held
0 ❑and/or Address
F Hold
co,
Date Point of
:Q Transportation Shipment
25 by Common. Destination
Carrier
Q Disinterment Date Cemetery Address
Renterment 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
82 Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
a Address
It
W.
CL
Permission is hereby granted to dispose of the human re ains described above as indicated.
Date Issued 3/9/201 7 Registrar of Vital Statistics 4,-)?A‘S. de)
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:
i� 4 t
Iu Date of Disposition ails j i i Place of Disposition rtWti� (Pum ear1Ow
2 (address)
tu
ta
CC (section) A (lot number) (grave number)
ta Name of Sexton or Person in Charge of Premises G &.i r _ii
// (pl(Timber)
print)
Signature I L Title MC W—
(over)
DOH-1555 (02/2004)