Gowett, Josephine NEW YORK STATE DEPARTMENT OF HEALTFI`' 's lli
ft t°I
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Josephine Gowett Female
Date of Death Age If Veteran of U.S. Armed Forces,
in 1 /2 7/201 5 91 y r s. War or Dates No
#-- Place of Death Town of Hospital, Institution or
1 City, Town or Village Ticonderoga Street Address Moses-Ludington Hospital
Manner of Death ��! Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
tu Medical Certifier Name Title
Todd R. Waldorf D.O.
Address
1019 Wicker Street, Ticonderoga, NY 12883
giiii Death Certificate Filed Town of District Number Register Number
gil City, Town or Village Ticonderoga 1 564 d�
i''i ❑Burial Date Cemetery or Crematory
❑Entombment 1 /30/201 5 Pine View Crematory
Address
®Cremation Queensbury, New York
Date Place Removed
Z n Removal and/or Held
t and/or
Address�
Cl)
Hold
0 Date Point of
tn Transportation Shipment
0 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
Bii 11 Algonkin St. , Ticonderoga, NY 12883
gilii Name of Funeral Firm Making Disposition or to Whom
.14 Remains are Shipped, If Other than Above
Address
t
Ui
Permission is hereby granted to dispose of the human re ins described above as indicated.
iifi Date Issued 1 /30/201 5 Registrar of Vital Statistics/ -G4 I
(signature)
Ei District Number 1 564 Place Town of Ticonderoga
;:<:: I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
10.
ILI Date of Disposition if tlic Place of Disposition F46L, Lt (�
(address)
Cl)Ili
2 (section) j (lot number) (grave number)
CI Name of Sexton or Person in Cha ge of Premises (d/�^J^IL Semil
pleaseel; print)
,Si Signature Title I trivowl
(over)
DOH-1555 (02/2004)