Hanson, Elizabeth ..e , s, , it I l l
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Elizabeth F. Hanson Female
Date of Death Age If Veteran of U.S. Armed Forces,
03/12/2015 84 yrs. War or Dates No
1- Place of Death Town of Hospital, Institution or Heritage Commons
W City, Town or Village Ticonderoga Street Address Residential Health Care
W Manner of Death®Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
la Medical Certifier Name Title
d Todd R. Waldorf D.O.
Address
1019 Wicker Street, Ticonderoga, New York 12883
Death Certificate Filed Town of District Number Register Number
City, Town or Village Ti ponriarnrja 1 564 1 4
['Burial Date Cemetery or Crematory
❑Entombment 03/16/2015 Pine View Crematory
Address
:IiiialCremation Queensbury, New York
Date Place Removed
Z ❑Removal and/or Held
2 and/or Address
I! Hold
Cl)
0 Date Point of
3 0 Transportation Shipment
a 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
11 Algonkin St. , Ticonderoga, New York 12883
Riy Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
i
W.
P` Permission is hereby granted to dispose of the human r. s describe• -bove - ' •icated.
Date Issued 3/1 3/201 5 Registrar of Vital Statistics I ' I .
IV (si,, _ e)
District Number 1 564 Place Town of Tico .eroga
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ta Date of Disposition 3114l4 Place of Disposition -Fitt ,,,� ,Ot
(address)
iii
CC (section) (lot number (grave number)
Name of Sexton or Person in Charge of Premises "*L
Z (p ease print)
Signature A .L--- Title riztviiihalt.
(over)
DOH-1555 (02/2004)