Wiles, Geraldine illreriiilr
NEW YORK STATE DEPARTMENT OF HEALTH it '7°7
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Geraldine Joan Wiles Female
Niiii Date of Death Age If Veteran of U.S. Armed Forces,
Mil 09/25/2016 89 yrs. War or Dates No
} Place of Death Town Hospital, Institution or Heritage Commons
1Z City, Town or Village of Ticonderoga Street Address Res idnPfi i a 1 HPa 1 th Care
:{ Manner of Death 0 Natural Cause 0 Accident ❑Homicide ❑Suicide Undetermined 0 Pending
It Circumstances Investigation
CI
in Medical Certifier Name Title
CA Kathleen Huestis M.D.
Address
1019 Wicker Street, Ticonderoga, New York 12883
Death Certificate Filed Town of District Number Register Number
Mil City, Town or Village Ti rnnc7carnga 1 564 46
iiii❑Burial Date Cemetery or Crematory
QEntombment Address
201 6 Pine view Crematory
Address
®Cremation Queensbury, New York
Date Place Removed
Removal and/or Held
2 and/or
Address
H Hold
1/1
Date Point of
i;D Transportation Shipment
0 by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
iiiiii 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
1,4 Remains are Shipped, If Other than Above
2 Address
ILE
ir Permission is hereby granted to dispose of the human rem ins escribed above as indicated.
!Qii: Date Issued 0 9/2 7/2 01 6 Registrar of Vital Statistics it.S.'(�,
Q (signature)
`:' District Number 1 564 Place Town of Ticonderoga
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I
Ilk Date of Disposition 116f3110 Place of Disposition iwU r �
2 (address)
Lu
ta
re (section) l (lot number) (grave number)
Ci: Name of Sexton or Person in Charge of Premises <h t, Scn4IQ�
.z *ease print)
Signature Gil ch.. Titlet Aitlit
(over)
DOH-1555 (02/2004)