Geisel, Inge NEW YORK STATE DEPARTMENT OF HEALTH f CO
Vital Records Section Burial - Tran it Permit
Name First Middle Last Sex
Inge E. Geisel Female
Date of Death Age If Veteran of U.S. Armed Forces,
12/20/2016 85 yrs. War or Dates No
Place of Death Town of Hospital, Institution or Heritage Commons
ill City, Town or Village Ticonderoga Street Address Residential Health Care
Manner of Death®Natural Cause 0 Accident 0 Homicide E Suicide 0Undetermined 0 Pending
Circumstances Investigation
iii Medical Certifier Name Title
o Robert J. Orr III M.D.
Address
102 Race Track Road, Ticonderoga, NY 12883
Death Certificate Filed Town of District Number Register Number
igi City, Town or Village Ticonderoga 1 564 59
aii ❑Burial Date Cemetery or Crematory
Li Entombment 12/22/2016 Pine View Crematory
Address
®Cremation Oueensbury, New York
Date Place Removed
Z ❑Removal and/or Held
and/or Address
M= Hold
ODate Point of
ii 1-1
th Li Transportation Shipment
C by Common Destination
Carrier
El Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
<' Permit Issued to Registration Number
Name of Funeral Home Wilcox & Regan funeral home 01 821
Address
Mi 11 Algonkin St. , Ticonderoga, NY 12883
Ni Name of Funeral Firm Making Disposition or to Whom
• Remains are Shipped, If Other than Above
• Address
w
Permission is hereby granted to dispose of the human remains described above as indicated.
ffl Date Issued 1 2/22/201 6 Registrar of Vital Statistics 1/4.1/-14.6)
ISCII,4
(sig Lure)
ig 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:
1-
tf Date of Disposition r 2/23/4, Place of Disposition 1 i�0 O fet,J G re�a 4-77
2 (address)
tf
CC (section) )i C� lot number) (grave number)
Name of Sexto j.Person in Charge of Premises J /LA r? 64- C�� e
(please print)
Signature Title C_/c Pr./a- I-a.-
(over)
DOH-1555 (02/2004)