Floor, Marjorie . 0NEW YORK STATE DEPARTMENT OF HEALTH I
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Rev. Marjorie J. Floor Female
Date of Death Age If Veteran of U.S. Armed Forces,
March 1 , 201 7 83 yrs. War or Dates No
.i Place of Death Town of Hospital, Institution or
77 Sabbath Day Point
III City, Town or Village Hague Street Address Silver Bay
0 Manner of Death 0 Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
LtiCircumstances Investigation
ul Medical Certifier Nam Titlg�
/If mite Zak t it s f�'11
Address
/6 / egy '. e nsLary A'Y - /1 Pa 11
<> Death Certificate Filed Town of District Number Register Number
City, Town or Village Hague 5653 02
Eii❑Burial Date Cemetery or Crematory
❑Entombment 3/3/2017 Pine View Crematory
Address
®Cremation Oueensbury, New York
Date Place Removed
Z Removal and/or Held
2❑and/or Address
F Hold
CD
0 Date Point of
ftTransportation Shipment
0 by Common. Destination
Iiiiiii Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Wilcox & Regan funeral home 01 821
Mi Address
ilii 11 Algonkin St. , Ticonderoga, New York 12883
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
tr
tI
P.'` Permission is hereby granted to dispose of the human rjmains describ b ve as in ed.
g �. ,�iC f
Date Issued 3/2/2 01 7 Registrar of Vital Statistics f+�ajt. u -�-
ignaturey I
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District Number 5653 Place Town of Hague
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certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
LL. Date of Disposition 313i n Place of Disposition 'gni V ( t�et;,.-
2 (address)
1UJ
U,
CC (section) {� (lot number) CC (grave number)
nName of Sexton or Person in Charge of P emises (hns lr.- ,]i,,slf
Z (pease print)
10
Si nature 1 - � Title IgErAPPt2
9
(over)
DOH-1555 (02/2004)