Rowland, Dorothy c 1,1
NEW YORK STATE DEPARTMENT OF HEALTH i g31 Vital Records Section Burial - Transit Permit
iRi Name First Middle Last Sex
Dorothy Corr Row? nd Female
Date of Death Age it teran of U.S. Armed 1-orces,
11 /20/2016 94 yrs. War or Dates No
1 Place of Death Hospital, Institution or
Town of Heritage Commons
City, Town or Village Ticonderoga Street Address Residential Health carp
0 Manner of Death Natural Cause 0 Accident 0 Homicide u Suicide �Undetermined Pending
ILIE Circumstances Investigation
j Medical Certifier Name Title
Richard McKeever M.D.
Address
1019 Wicker Street, Ticonderoga, New York 12883
Death Certificate Filed Town of District Number Register Number
City, Town or Village Ticonderoga 1 564 53
'< OBurial Date Cemetery or Crematory
QEntombment 11 /22/201 6 Pine View Crematory
Address
®Cremation Queensbury, New York
Date Place Removed
.4 El❑Removal and/or Held
few and/or Address
t: Hold
0 Date Point of
Transportation Shipment
C by Common Destination
Carrier
<` Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
!!pi Liigi Permit Issued to Registration Number
MI Name of Funeral Home Wilcox & Regan funeral home 01 821
iM Address
11 Algonkin St. , Ticonderoga, New York 12883
Egiii Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
It
III-
IL
Permission is hereby granted to dispose of the human re ins described above as indicated.
Wi Date Issued 1 1 /21 /2 01 6 Registrar of Vital Statistics
si ature)
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:
ui Date of Disposition ///t3//E Place of Disposition ,,A-. (baton...
2 (address)
la
to
lc (section) / (lot number) (grave number)
ei Name of Sexton or Person in Charge of Premises iiigivf Stott'
please print)
Signature i Title l 11h
(over)
DOH-1555 (02/2004)