Loading...
Davis, Sally , NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex Sally A. Davis Female Date of Death Age If Veteran of U.S. Armed Forces, 09/20/201 6 86 yrs. War or Dates No Place of Death Hospital, Institution or Town of Heritage Commons City, Town or Village Ticonderoga Street AddressIII Residentiale Health Care Manner of Death Ea Natural Cause Accident Homicide Suicide Undetermined 0 Fending til Circumstances Investigation Ca tu Medical Certifier Name Title 0 Richard McKeever M.D. Address 1019 Wicker Street, Ticonderoga, New York 12883 Death Certificate Filed Town of District Number Register Number City, Town or Village mii'rnderoga 1 564 45 li ❑Burial Date Cemetery or Crematory 9/21 /2016 Pine View Crematorium i €❑Entombment Address ©Cremation Queensbury, New York Date Place Removed ❑Removal and/or Held and/or Address I= Hold Date Point of t Q Transportation Shipment G f by Common Destination Carrier ❑Disinterment Date Cemetery Address �]Reinterment Date Cemetery Address iii '! Permit Issued to Registration Number Name of Funeral Home Mason Funeral Home 01 1 1 7 Address 18 George St. , P.O. Box 277, Fort Ann, New York 12827 r. Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above a Address Et IL Permission is hereby granted to dispose of the human remai scribed a ye as i •i ated. Date Issued 9/21 /201 6 Registrar of Vital Statistics y /, F, a7,„ (sig - e) District Number 1 564 Place Town of Ticonderoga certify that the remains of the decedent identified above were disposed of in accordance with this permit on: 2 U Date of Disposition Place of Disposition (address) tEl 0 CC (section) (lot number) (grave number) a Name of Sexton or Person in Charge of Premises (please print) ii Signature Title (over) DOH-1555 (02/2004) „�.-...a,., ,CC: I PAGE 01 NEW YORK STATE DEPARTMENT OF HEALTH J Vital Records Section Burial - Tr nsit Permit `p,: Name First Middle Last Sex ' Sally A. Davis Female zt Date of Death Age If Veteran of U_S_Armed Forces, A>j 0 9/-2 0/2 016 _ 86 y r s. War-of Dates NO Y`: Place of Death Hospital, Institution or Town of Heritage Commons City, Town or Village TiCO�dRr c� Street Address _ . Manner of Death Natural Cause Q Accident El Homicide Q Suicide [� •etermrried ”e •irig Circumstances Investigation 1 Medical Certifier Name Title Richard McKeever M.D. `'}"IX Address 1019 Wicker Street, Ticonderoga, New York 1 883 ;,� Death Certificate Filed Town of District Number Regter Number "'x City, Town or Village T r r •l ''fi 5.64 4 5 ?❑Burial Date Cemetery or Crematory < 9/21 /201� Pine View CYerilat:or in,.DEM° nest Address - __,®Cremation _-Queensbu.>ry. New York --- ::sr: Date Peace Removed E .I Removal LL and/or Held and/or Address Hold _ • Date Point of • I(Transportation Shipment ,> t by Common Destination hi t ''rA' Date Cemetery Address :',.il❑Disinterment " Date Cemetery Address ;:.: '`�_` Reintarment r>: Permit Issued to Regiltration Number ;iA Name of Funeral Home Mason Funeral Home 0 111 7 7 Address „t 'sr 18 Georae St. . P.O. Box 277, Fort. un, N w Yor 12827 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Address Permission Is hereby granted to dispose of the human remai 'bed si as i lcated- itE Date issued 9/21 /2 016 Registrar of Vital Statistics ) a7 —. Ni,',Eil District Number Place i 5 Town cif Ti ersnd resga ;::,; I certify that the remains of the decedent identified above were disposed of in accordancewith this permit on: Date of Disposition 9/u l/6 Place of Disposition MVir �mq O(r. _. (address) (section) (lit rne»berr) (grave nwnba). i Name of Sexton or Person in Charge of Premises 'f•' r J 1 1 t i ( laso print) i signature a .'�azl Title 0 po U�- (over) DOH-1555 (02/2004)