Perkins, Anna NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
;:. Name First Middle Last Sex
Anna Mae Perkins Female
1 Date of Death Age If Veteran of U.S. Armed Forces,
11 /05/201 7 77 yrs. War or Dates No
Place of Death Hospital, Institution or
Town of
t City, Town or Village Hague Street Address 9735 Graphite Mountain Rd.
Manner of Death Natural Cause 0 Accident 0 Homicide 0 Suicide ri Undetermined r7 Pending
Circumstances Investigation
III 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
iik City, Town or Village Hague 5653 09
Mii❑Burial Date Cemetery or Crematory
[]Entombment 1 1 /07/201 7 Pine View Crematory
Address
'0Cremation Oueensbury, New York
Date Place Removed
Z❑Removal and/or Held
and/or Address
ittHold
Date Point of
toil'0 Transportation Shipment
G by Common Destination
ip Carrier
Q Disinterment Date Cemetery Address
Date Cemetery Address
Q Reinterment
Nii 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
1U
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11 /7/201 7 Registrar of Vital Statistics exit4- -77/- 74ct.,,f—e6---
/ ' (signature)
District Number 5 6 5 3 Place -Tow in o 4 Wad u e
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
lid Date of Disposition i(/1 1 j) Place of Disposition
0 , � o--.4
(address)
W
t
re (section) /1, (lot number) (grave number)
Name of Sexton or Person in Charge of Premises
L'""t cn°4ri�'
t (pl ase print)
t etSignature Title OWL
DOH-1555 (02/2004)