Budwick, Kimberlee NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Kimberlee Jane Budwick Female
Date of Death Age If Veteran of U.S. Armed Forces,
December 21 , 2016 58 yrs. War or Dates No
1 Place of Death Hospital, Institution or
Town of
City, Town or Village Ticonderoga Street Address Moses-Ludington Hospital
p Manner of Death❑Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined Pending
MI Circumstances Investigation
ill Medical Certifier Name Title
C. Francis Varga M.D.
Address
P.O. Box 768, Lake Placid, NY 12946
Death Certificate Filed Town of District Number Register Number
City, Town or Village Ticonderoga 1 564 60
['Burial Date Cemetery or Crematory
_12/23/2016 Pine View Crematory
:❑Entombment Address
::: ®Cremation Queensbury, New York
Date Place Removed
❑Removal and/or Held
and/or Address
F,.Th. Hold
O Date Point of
4 Transportation Shipment
t
0 by Common Destination
Si Carrier
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 12883
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
;'; Address
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` Permission is hereby granted to dispose of the human rem ins describe ab ye as indicated.
Date Issued 1 2/2 2/2 01 6 Registrar of Vital Statistics ; e (' c
(sig ture)
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:
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tit Date of Disposition/2 2L / Place of Disposition , E,t/, ,re.- ; ky
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2 (address)
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CC (section) \
/' (lot number) (grave number)
Name of Sexton P r n in Charge of Premises `J k iiG 1[ ,�i , €
r (please print)
ILI Signature 4_, Title G ri-in ��
(over)
DOH-1555 (02/2004)