Freitas, Cherry NEW YORK STATE DEPARTMENT OF HEALTH 38:3
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Cherry Laverne Freitas Female
Date of Death Age If Veteran of U.S. Armed Forces,
05/22/2016 62 yrs. War or Dates No
Fi4 Place of Death Town of Hospital, Institution or
Z Cit11.ty, Town or Village Ticondprr a Street Address 91 Putts Pond Road
Manner of Death®Natural Cause Li Accident Ei Homicide El Suicide Undetermined ri Pending
Circumstances Investigation
W Medical Certifier Name Title
0 Darci Gaiotti-Grubbs M.D.
Address
102 Park Street, Glens Falls, NY 12801
Death Certificate Filed Town of District Number Register Number
City, Town or Village Ticonderoga 1 564
0 Burial Date Cemetery or Crematory
[]Entombment 5/24/201 6 Pine View Crematory
Address
®Cremation Queenshury, New York
Date Place Removed
Z Removal and/or Held
1❑and/or
� Address
VI
Hold
0 Date Point of
Q Transportation Shipment
0 by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Q 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 12881
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
cr
tt
Permission is hereby granted to dispose of the human rem ' s describe bo s indicated.
Date Issued 5/2 4/2 01 6 Registrar of Vital Statistics
(ft-1 / -
signature) '
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:
ILI r '
Date of Disposition 1--24-do Place of Disposition �,,1V,,� ei-tmc,,re--
(address)
Ui
CC
CC (section) (lot numb (grave number)
CC
Name of Sexton or Person in Charge of P mises d
_) B*�'
z ? (p ase print)
Signature �- Title ("� L
(over)
DOH-1555 (02/2004)