Jones, Mae NEW YORK STATE DEPARTMENT OF HEALTHY----- . K' 1,
Vital Records Section Burial - Transit Permit
" ! Name First Middle Last Sex
Mae T,n„LSP Jones Female
; Date of Death Age If Veteran of U.S. Armed Forces,
May 10, 2016 84 yrs. War or Dates No
I-• Place of Death Town of Hospital, Institution or
ZCity, Town or Village Ticonderoga Street Address Montcalm Manor Adult Home
a Manner of Death Natural Cause ❑Accident ❑Homicide ❑Suicide ❑ Undetermined ri❑Pending
Ltt Circumstances Investigation
W Medical Certifier Name Title
CI Glen Chapman M.D.
Address
P.O. Box 29, Ticonderoga, NY 12883
Death Certificate Filed Town of District Number Register Number
City, Town or Village Ticonderoga 1 564
ElBurial Date Cemetery or Crematory
QEntombment 5/13/2016 Pine View Crematory
Address
®Cremation Queensbury, New York
Date Place Removed
Z❑Removal and/or Held
and/or Address
CA
0 Date Point of
EL r—i
Transportation Shipment
ci by Common Destination
Carrier
Q 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, NY 1 2883
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
! Address
Cr
fa
fl` Permission is hereby granted to dispose of the human re n describe o indicated.
gE Date Issued 5/1 2/201 6 Registrar of Vital Statistics "ti
( gnature)
District Number 1 564 Place Town of T onderoga
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
iii (� f
Date of Disposition ��[��(� Place of Disposition em-V,„� �rwQ
2 (address)
tESE
in
CC (section) (lot number) (grave number)
Name of Sexton or Person in Charge of remises a^� L '"Q`]�
z (plase pant)
ltt Signature6
Title C1'1:1'ft
(over)
DOH-1555 (02/2004)