McDonald, Dorothy # gilt)
NEW YORK STATE DEPARTMENT OF HEALtH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Dorothy S. McnnnaLd Female
Date of Death Age If Veteran of U.S. Armed Forces,
11 /0 5/201 7 93 years War or Dates No
Place of Death Town of Hospital, Institution or Heritage Commons
City, Town or Village Ticonderoga Street Address Residential Health Care
Manner of Death 0 Natural Cause El Accident El Homicide El Suicide El Undetermined ri Pending
Ij Circumstances Investigation
til Medical Certifier Name Title
Kathleen P. Huestis M_n_
Address
1019 Wicker Street, Ticonderoga, New York 12883
Death Certificate Filed Town of District Number Register Number
City, Town or Village Ticondernge 1 564 41
>'❑Burial Date Cemetery or Crematory
['Entombment1 1 /09/201 7 Pine View Crematory
Address
;:;:::]Cremation Queensbury, New York
'W Date Place Removed
❑Removal and/or Held
9. and/or Address
M= Hold
CO
0 Date Point of
Transportation Shipment
G by Common Destination
Carrier
ID Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Mi Name of Funeral Home Wilcox & Regan funeral home 01 821
Address
ol
11 Algonkin St. , Ticonderoga, New York 12883
j Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2' Address
5
Permission is hereby granted to dispose of the human remains d scribed above as indicated.
Date Issued 1 1 /8/2 01 7 Registrar of Vital Statistics /x(Y i t
3 (signature)
; District Number 1 564 Place Town of Ticonderoga
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
pp
t Date of Disposition /O O)S in Place of Disposition T,r, LJ (...�-ice
2 (address)
Cl)ILI
CC (section) (lot number) c (grave number)
ta Name of Sexton or Person in Charge of Premises Lbr. l^1�U, ✓ y�
( lease print)
Signature4 Title caomA W-
(over)
DOH-1555 (02/2004)