LaRock, Cheryl NEW YORK STATE DEPARTMENT OF HEALTH y'
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Cheryl Lynn LaRock Female
Date of Death Age If Veteran of U.S. Armed Forces,
11 /26/2015 59 yrs. War or Dates No
Place of Death Town of • Hospital, Institution or
City, Town or Village Ticonderoga Street Address 1 1 8 Burgoyne Road
a Manner of Death®Natural Cause ❑Accident 0 Homicide 0 Suicide ElUndetermined Ei Pending
Circumstances Investigation
W Medical Certifier Name Title
G Glen Chapman M.D.
Address
P.O. Box 29, Ticonderoga, NY 12883
Death Certificate Filed Town of District Number Register Number
City, Town or Village Ticonderoga 1 564 64
❑Burial Date Cemetery or Crematory
11 /30/2015 Pine view Crematory
; ['Entombment Address
•;::Cremation Queensbury, New York
Date Place Removed
❑Removal and/or Held
and/or
F;;; Address
CA
Hold
0 Date Point of
il
❑Transportation Shipment
G by Common Destination
qii Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
M. Permit Issued to Registration Number
Name of Funeral Home Wilcox & Regan funeral home 64
Address
ft 11 Algonkin St. , Ticonderoga, New York 12883
Name of Funeral Firm Making Disposition or to Whom
▪ Remains are Shipped, If Other than Above
a Address
2
Ui
fL Permission is hereby granted to dispose of the human re ins described above as indicated.
Date Issued 1 1 /29/201 5 Registrar of Vital Statistics /YJ • GC.�L2--,—..
(signature)
gi 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:
U
t� Date of Disposition f Z(2(�� Place of Disposition �+u v,,, Irr-cltd(...._
2 (address)
Il
to
c (section) �� (lot number) (grave number)
fa Name of Sexton or Person in Charge of Premises t;• �- S-s�t,-�11-
f (phrase print)
• Signature A ,4‘h,G , Title atAlifk
(over)
DOH-1555 (02/2004)