Knight, Shirley NEW YORK STATE DEPARTMENT OF HEALTH Burial -
Vital Records Section ansit Permit
Name First Middle Last Sex
Shirley Kathryn Kni ht Female
Date of Death Age If-Veteran of U.S. Armed-Forces,
March 5, 2015 86 yrs War or Dates No
Place of Death Town of Hospital, Institution or
City, Town or Village Ticondarotja Street Address 28 The Portage
0 Manner of Death 0 Natural Cause El Accident ❑Homicide El Suicide El Undetermined ❑Pending
W Circumstances Investigation
Ili Medical Certifier Name Title
Glen Chapman M.D.
Address
102 Race Track Road, Ticonderoga, NY 12883
Death Certificate Filed Town of District Number Register Number
City, Town or Village Ticonderoga 1 564
NI❑Burial Date Cemetery or Crematory
03/09/2015 Pine View Crematory
❑Entombment Address
@Cremation Queensbury, New York
Date Place Removed
Z El Removal and/or Held
and/or
�; Address
t
CA
Hold
O Date Point of
to Li Transportation Shipment
O by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Ii!<l Permit Issued to Registration Number
Name of Funeral Home Wilcox & Regan funeral home 01 821
Address
11 Algonkin St. , Ticonderoga, NY 12883
qlil Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
• Address
IX
AW
fl` Permission is hereby granted to dispose of the human rema' d scribed abo as in i ted.
•
iiliiiiiili Date Issued 03/0 6/201 5 Registrar of Vital Statistics
(signs ur
II District Number 1 564 Place Town of Tico eroqa
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
y
I Date of Disposition 3/►oIi Place of Disposition k�!-+ ceeisto4
(address)
W
V
ti (section) (lot number) (grave number)
ci Name of Sexton or Person in Charge of Premises /��:s Se...i `'
Z ,/ (pl ase print)
Signature Title iTLi: �
oi
(over)
DOH-1555 (02/2004)