Bush, Theresa if4 lout
t
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section P •- - ' Burial - Transit Permit
iilig Name First Middle Last Sex
Theresa Mary. Bush Female
Date of Death Age If Velran of U.S. Armed Forces,
08/28/201 6 85 yrs. War or Dates No
Place of Death Town of Hospital, Institution or
City, Town or Village Ticonderoga Street Address 1 28 The Portage
lit0 Manner of Death®Natural Cause 0 Accident 0 Homicide 0 Suicide ElUndetermined El Pending
tt Circumstances Investigation
U.
Medical Certifier Name Title
0 Glen Chapman M.D.
Address
102 Race Track Road, Ticonderoga, NY 12883
Death Certificate Filed Town of District Number Register Number 3
City, Town or Village Ticonderoga 1 564iiiii I
❑Burial Date Cemetery or Crematory
iii ['Entombment08/30/201 6 Pine View Crematory ,
Address
Ni®Cremation Queensbury, New York
Date Place Removed
❑Removal and/or Held
- and/or Address
i"" Hold
415 Date Point of
) El Transportation Shipment
C by Common Destination
Carrier
Disinterment Date Cemetery Address
lie
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Wilcox & Regan funeral home 01 821
;iii: Address
11 Algonkin St. , Ticonderoga, New York 12883
Mii Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
a Address
Ili
Permission is hereby granted to dispose of the human rem 'ns described above as indicated.
Date Issued 8/29/201 6 Registrar of Vital Statistics L, 5/74 a
(sign re)
El 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:
k
LEI Date of Disposition I/30 ia, Place of Disposition Pr.," a.-14,...
(address)
Ili
fa
CC (section) (lot number) (grave number)
O.
it1 Name of Sexton or Person in Char a of Premises r'i St,",�
(please print)
11 Signature Title ae 1t VW-
(over)
DOH-1555 (02/2004)