Monty, Clara 92G
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Clara T,o1a Monty Female
Date of Death Age If Veteran of U.S. Armed Forces,
1 2/2 3/2 01 6 71 yrs. War or Dates No
j- Place of Death Town of Hospital, Institution or 1 007 Wicker Street
City, Town or Village Ticonderoga Street Address Apt. 305
Manner of Death❑ Natural Cause El Accident 0 Homicide 0 Suicide El Undetermined R Pending
Circumstances Investigation
tg Medical Certifier Name Title
0 C_ Francis Varga M_D_
Address
P.O. Box 768, Lake Placid, NY 12946
Death Certificate Filed Town of District Number Register Number
City, Town or Village Ticonderoga 1 564
: <❑Burial Date Cemetery or Crematory
12/27/2016 Pine View Crematory
ffi DEntombment Address
®Cremation Queensbury, New York
Date Place Removed
❑Removal and/or Held
X. and/or Address
w= Hold
in
0 Date Point of
11 El Tr0. ansportation Shipment
G by Common Destination
Nii_ 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
O 11 Algonkin St. , Ticonderoga, New York 12883
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
cc
la
P. Permission is hereby granted to dispose of the human remains ribed abo as incl. ted.
Date Issued 12/27/2016_ Registrar of Vital Statistics /�(signaif/
District Number 1 564 Place Town of Ticond roga
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ti
ILI Date of Disposition r2/Z8//(o Place of Disposition Pik1 U t Z& C/ayrlca v/'
2 (address)
ill
0
CC (section) (lot number) (grave number)
Name of Sexton r on in Charge of Premises t.,.. )r G-et Ca.k.,"'t d
2 (please print)
Ill Signature Title C Uzi
(over)
DOH-1555 (02/2004)