Huestis, Anne NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
<> Name First Middle Last Sex
Anne Katherine Huestis Female
'> Date of Death Age If Veteran of U.S. Armed Forces,
1 0/1 2/2 01 5 67 y r s. War or Dates No
14 Place of Death Town of Hospital, Institution or Heritage Commons
City, Town or Village Ticonderoga Street Address RPs i rlPnti al Health Care
Manner of Death Px Natural Cause 0 Accident El Homicide 0 Suicide Undetermined ri Pending
tEE Circumstances Investigation
LI
tu Medical Certifier Name Title
C Richard McKeever M.D.
Address
1019 Wicker Street, Ticonderoga, New York 12883
Death Certificate Filed Town of District Number Register Number
City, Town or Village Ti condProga 1 564 54
3❑Burial Date Cemetery or Crematory
i:T`7ElEntombment 10/14/2015 Pi.nP \Liew Crematory
Address
Cremation Queensbury, New York
Date Place Removed
t ❑Removal and/or Held
and/or Address
14 Hold
VI
Date Point of
11L Transportation Shipment
E' by Common Destination
Carrier
Q Disinterment Date Cemetery Address
'' Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Wilcox & Regan funeral home 01 821
Address
11 Algonkin St. , Ticonderoga, New York 12883
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above ,
Address
CC
W.
Permission is hereby granted to dispose of the human re ains described above as indicated.
iiiz
Date Issued 1 0/1 4/201 5 Registrar of Vital Statistics hi* a , ,
a (signature)
District Number 1 564 Place Town of Ti conderoga
i
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
lif Date of Disposition 1°/1///5' Place of Disposition Alt—i cloy,---
2 (address)
Ill
CA
CC (section) /� (lot nurryer) (grave number)
ci Name of Sexton or Person in Ch rge of Premises ` r" JL'"z
/7� ► (please print)
" !mil- '
Signature �T Titlen$104-
(over)
DOH-1555 (02/2004)