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May, Ida 4 ti NEW YORK STATE DEPARTMENT OF HEALTH If b t/9 I Vital Records Section Burial - Transit Permit <i Name First Middle Last 1 Sex Ida M. May Female Date of Death , Age i if Veteran of U.S. Armed Forces, s. September 13 , 2016 86 yrs. War or Dates No Place of Death Town of Hospital, Institution or Z City, Town or Village I. g e Street Address 1 22 New Hague Road © Manner of Death X Natural Cause n Accident ____Homicide n Suicide C Undetermined [ Pending — Circumstances Investigation Medical Certifier Name Title O 'e.nn -c't— L• S-'ra "o r1 K ."Z- Address 16 ( 0_)c3-k--e1 Road. Qut,.��. s b mil-y 1 xi-y laRot-t- iliiii Death Certificate Filed Town of ' District Nuhiber Register Number til City, Town or Village Hague 5653 J O Date T Cemetery or Crematory IBurial 09/15/2016 Pine View Crematory Address Pi( Cremation Oueensbury, New York Date Place Removed Z n Removal and/or Held and/or Address 5 Hold Q • Date 7 Point of Nn Transportation j Shipment a by Common Destination Carrier n Disinterment Date T Cemetery Address Reinterment Date Cemetery Address >i Permit Issued to Registration Number >` Name of Funeral Home Wilcox & Regan funeral home 01 821 `<s Address 11 Algonkin St. , Ticonderoga, New York 12883 '.i'. Name of Funeral Firm Making Disposition or to Whom wRemains are Shipped, If Other than Above Address AU Permission is hereby granted to dispose of the human emains described ab ove as i dicated. iii>< Date Issued 9/1 5/2 01 6 Registrar of Vital Statistics �Cb'JJ)�`� ��77'I A n orb (signal re) District Number) Place - I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: .f f' ill Date of Disposition 1'f/6// Place of Disposition „gt(),�•✓ C rp-- (address) J1J CC (section) //lot number)( (grave number) flName of Sexton or Person in Char e of Premises 6��1�4-r' Jt►�/1��` (please print)Ui Signature (Al Title GR.w+t1Y2.DOH-1555 (10/89) p. 1 of 2 VS-61