Pelerin, Shirley NEW YORK STATE DEPARTMENT OF HEALTH AMr No
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Shirley Ann Pelerin Female
1. Date of Death Age If Veteran of U.S. Armed Forces,
02/12/2016 78 yrs. War or Dates No
14 Place of Death Town of Hospital, Institution or
Z City, Town or Village Ticonderoga Street Address 2353 NYS Route 74
W Manner of Death X❑Natural Cause El Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
W 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 1 564 8
❑Burial Date Cemetery or Crematory
2DEntombment Ad2d1dress6/2016 Pinc Vicw Crematory
::;:i ®Cremation Queensbury, New York
Date Place Removed
ZEl Removal and/or Held
....� and/or Address
F= Hold
t/?
0 Date Point of
In L_I Transportation Shipment
O by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
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
Remains are Shipped, If Other than Above
• Address
ft
iI
Permission is hereby granted to dispose of the human remain de-cribed .•r.ve : - i,dicated.
Date Issued 2/1 5/201 6 Registrar of Vital Statistics /, /
g ture)
District Number 1 564 Place Town of Ticon.eroga
l` I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
tit Date of Disposition Zito/A. Place of Disposition Pitt04,r, Cfr0 (Z'%,..,
Ili (address)
VI
its (section) /��/t/ (lot number (grave number)
CI Name of Sexton or Person in Charge of Premises (hi^„ ,-�r 3iM 'r
z (please print)
Ul a
Signature ` 1�� Title (lifilliftrAt
(over)
DOH-1555 (02/2004)