Hebert, Cecilia IW Ytf3K STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Cecilia 0_ Hebert Femalc
Date of Death Age If Veteran of U.S. Armed Forces,
12/17/2015 93 yrs. War or Dates No
-14 Place of Death Town of Hospital, Institution or Heritage Commons
il City, Town or Village Ticonderoga Street Address Residential Health Care
• Manner of Death j Natural Cause 0 Accident Homicide Suicide Undetermined 0 Pending
/ Circumstances Investigation
Ili Medical Certifier Name Title
Kathleen A. Huestis M.n_
Address
Mi 1019 Wicker Street, Ticonderoga, NY 12883
iiiiiiiii Death Certificate Filed Town of District Number Register Number
City, Town or Village micQnr(Arora 1 5f 4 68
0 Burial Date Cemetery or Crematory
❑Entombment 1 2/21 /201 5 Ping. View Crematory
Address
®Cremation Oueensbury, New York 12tbil
Date Place Removed
• Removal and/or Held
9 and/or
Address
fin.
Hold
O Date Point of
Transportation Shipment
C by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Wilcox & Regan funeral home 01 821
Address
iill 11 Algonkin St. , Ticonderoga, New York 12883
z Name of Funeral Firm Making Disposition or to Whom
• Remains are Shipped, If Other than Above
;'; Address
CC
ILI
CL
Permission is hereby granted to dispose of the human rema' scribe ove s indicated.
iiig! Date Issued 1 2/1 8/2 01 5 Registrar of Vital Statistics e 7(J'W)12&ON.
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District Number 1 564 Place Town of Ti
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
ILI Date of Disposition /2-21.-IS Place of Disposition ) ,' ,Q 11 a J 6reA2,01-o/y
2. (address)
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CC (section) ‘ „got
of number) (grave number)
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▪ Name of Sexton r Per on in Charge of Premises N t-- Ark. &✓ i a-e..,4 e
Z (please print)
I / Title Carr► ®_i
giiSignature
(over)
DOH-1555 (02/2004)