Batovec, Vlasta NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Vlasta Marie Batovec Female
Date of Death Age If Veteran of U.S. Armed Forces,
10/23/2015 97 yrs. War or Dates No
I- Place of Death Town of Hospital, Institution or Heritage Commons
Z City, Town or Village Ticonderoga Street Address Residential Health Care
a Manner of Death 69 Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
W Circumstances Investigation
tu Medical Certifier Name Title
Richard McKeever M_n_
Address
1019 Wicker Street, Ticonderoga, New York 12883
Death Certificate Filed Town of District Number Register Number
City, Town or Village Ticonderoga 1 564 58
❑Burial Date Cemetery or Crematory
10/27/2015 Pine View Crematory
❑Entombment Address
n®Cremation Queensbury, New York ___
Date Place Removed
Z ❑Removal and/or Held
2 and/or Address
I= Hold
CO
0 Date Point of
Trin ansportation Shipment
O by Common Destination
Carrier
El Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Wilcox & Regan funeral home 01821
Address
11 Algonkin St. , Ticonderoga, New York 12883
Name of Funeral Firm Making Disposition or to Whom
}- Remains are Shipped, If Other than Above
2 Address
tr
t
Permission is hereby granted to dispose of the human rem ins described above as indicated.
Date Issued 1 0/26/201 5 Registrar of Vital Statistics _it /}') t G �
(signature)
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:
1.
�
I Date of Disposition ID roil r Place of Disposition illy Cn,to,.._.
2 (address)
Ili
VI
CC (section) /// (lot number (grave number)
fa Name of Sexton or Person in Charge of Premises ( 4 t� 3R
.Z. ( lease print)
Signature (� Title < �4P.�
(over)
DOH-1555 (02/2004)