McIntyre, Myrtle NEW YORK STATE DEPARTMENT OF HEALTH ! 1 '
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Myrtle Marie McIntyre Female
Date of Death Age If Veteran of U.S. Armed Forces,
11 /23/201 7 91 yrs _ War or Dates Nn
I- Place of Death Town of Hospital, Institution or
iliZ City, Town or Village Putnam Station Street Address 1 01 6 County Rte. 2
ct Manner of Death®Natural Cause 0 Accident D Homicide D Suicide riUndetermined 0 Pending
ILI
Circumstances Investigation
ill Medical Certifier Name Title
fl Kathleen p. Huestis M.D.
Address
P.O. Box 29 , Ticonderoga, New York 12883
Death Certificate Filed Town of District Number Register Number ii
City, Town or Village Putnam Station 9763
:1❑Burial Date Cemetery or Crematory
.:. Entombment 11 /27/2017 Pine View Crematory
Address
®Cremation Queensbury, New York
Date Place Removed
❑Removal and/or Held
and/or Address i
CO
Hold
0 Date Point of
EL
Q Transportation Shipment
0 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 Algonktn St. , Ticonderoga, New York 12883
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
cr
fI
!` Permission is hereby granted to dispose of the human ains de cribed above as indicated.
Date Issued 1 1 /2 6/201 7 Registrar of Vital Statistics
(signatu )
District Number 576 3 Place . / C0 Got, Q 44. n a Ai . -&*in n
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
t1 Date of Disposition wig in Place of Disposition f-u. ` n,wr -v
W (address)
tO
IX (section) (lot number) �` (grave number)
ta Name of Sexton or Person in Charge of Premises
ti•r3tt .'s �J IA.1at
(plelise print)
Signature inr Title alEntb+?..- •
(over)
DOH-1555 (02/2004)