Huestis, Ruth NEW YORK STATE DEPARTMENT OF HEALTH 3b
Vital Records Section ' , Burial - Transit Permit
Name First Middle Last Sex
Ruth R. Huestis Female
Date of Death Age If Veteran of U.S. Armed Forces,
7/1 3/2 01 2 90 y r s. War or Dates No
14 Place of Death Town of Hospital, Institution or Heritage Commons
Z. City, Town or Villa e g
i 9 Ticonderoc Street Address Residential Healthcare
Manner of Death Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
0Circumstances Investigation
ILI Medical Certifier Name Title
1 Todd R. Waldorf D.O.
Address
1019 Wicker Street, Ticonderoga, NY 12883
Death Certificate Filed Town of District Number Register Number
City, Town or Village Ticonderoga 1 564 39
❑Burial Date Cemetery or Crematory
7/16/2012 Pine View Crematory
d: ❑Entombment Address
@Cremation Queensbury, New York
Date Place Removed
Z❑Removal and/or Held
2 and/or Address
t Hold
tb
0 Date Point of
Q a Transportation Shipment
G by Common Destination
Rii 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
EN Address
11 Algonkin St. , P.O. Box 543, Ticonderoga, NY 12883
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
t
` Permission is hereby granted to dispose of the human rem ' escribe• - :•ve :- dicated.
Date Issued 7/16/2012 Registrar of Vital Statistics ' '
( .-tune)
District Number 1 564 Place Town of Ticond oga
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
r�
I Date of Disposition iota lit Place of Disposition jµV. .Cr-,T0rri.
(address)
lAi
CC (section) if
(lot number) c (grave number)
Name of Sexton or Pers in Char of Premises 1 lw4f'
(please print)
-47 Signature Title OWL-ONTO let-
(over)
DOH-1555 (02/2004)