Larson, June . . ) (pv
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Tune Eliz Beth Lar n Female
Date of Death Age Veteran of U.S. Armes Forces,
07/12/2017 86 yrs _ War or Dates No
Place of Death Hospital, Institution or
Town of
City, Town or Village Ticonderoga Street Address 1 560 NYS Rte. 9N
a Manner of Death❑X Natural Cause ❑Accident ❑Homicide ❑Suicide ri❑Undetermined El❑Pending
Circumstances Investigation
to Medical Certifier Name Title
0 Glen Chapman M_D_
Address
P.O. Box 29, Ticonderoga, New York 12883
Death Certificate Filed Town of District Number Register Number
City, Town or Village Ticonderoga 1 SF4 25
Mii❑Burial Date Cemetery or Crematory
DEntombmenthii: 7/20/201 7 P; ne i V ec.z m Crent y nr
Address
gCremation Oueensbury, New York —_
Date Place Removed
Removal and/or Held
and/or Address
: Hold
I
0 Date Point of
to Li Transportation Shipment
a by Common Destination
iiiii Carrier
Disinterment Date Cemetery Address
mi LiReinterment Date Cemetery Address
:iig ElPermit 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
Z.
i
CL
Permission is hereby granted to dispose of the human re i describe boy indicated.
Mi
Date Issued 7/1 4/2 01 7 Registrar of Vital Statistics
(si ure)
District Numberl 564 Place Town of Ticonderoga
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
ILI Date of Disposition /zi/i 7 Place of Disposition i hQ.L) J L
; .iro4 4,Jry
(addrehs)
Lu
CA
ir (section) r /l(lot number) (grave number)
Name of Sexton Pers in Charge of Premises J+-"t G�''` b ►"c.�'�`ti
(please print)
Iii iiiig Signature Title 4-
fL h,
(over)
DOH-1555 (02/2004)