Jordon, Beatrice NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
BPatrire Jordon Female
Date of Death Age If Veteran of U.S. Armed Forces,
March 2, 201 5 79 yrs. War or Dates No
Place of Death Town of Hospital, Institution or Heritage Commons
Z CitIii. y Town or Village Ticonderoga Street Address Residential Health Care
a Manner of Death Natural Cause 01 Accident 0 Homicide 0 Suicide
Undetermined ❑Pending
Circumstances Investigation
W Medical Certifier Name Title
0 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 1 1
['Burial Date Cemetery or Crematory
:i:❑Entombment O't/05/201 5 Pine Vi Pw Crematory
Address ,
g:::!::1®Cremation Queensbury, New York
Date Place Removed
Z n Removal and/or Held
P and/or
Address
t Hold
t/
0 Date Point of
85 Transportation Shipment
d by Common Destination
Carrier
❑Disinterment Date Cemetery Address
Ei!iQ Reinterment Date Cemetery Address
Riiiiil 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
tt
Ill
` Permission is hereby granted to dispose of the human rem ns described above as indicated.
Eili Date Issued 3/5/201 5 Registrar of Vital Statistics in " it-
(signature)
iii:dlli District Number 1 5 6 4 Place Town of Ticonderoga
:: a I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
gt� Date of Disposition 3/4/J-�- Place of Disposition l�UN., C P---
2 (address)
ILI
CC (section) (l number) . (grave number)
a Name of Sexton or Person in Charge of Premises „ J
ermot
(please'print)
Oa
S liii ignature Title
(over)
DOH-1555 (02/2004)