Benton, Ruth it
NEW YORK STATE DEPARTMENT OF HEALTH 37/
Vital Records Section •, Burial - Transit Permit
Name First • Middle Last Sex
Ruth M. Benton Female
Date of Death Age If Veteran of U.S. Armed Forces,
05/21 /201 5 70 yrs. War or Dates No
}- Place of Death Town of Hospital, Institution or Heritage Commons
ui City, Town or Village Ticonderoga Street Address Residential Healthcare
Manner of Death®Natural Cause p Accident E Homicide ElSuicide El Undetermined ❑Pending
Itii Circumstances Investigation
tgi Medical Certifier Name Title
0 Kathleen P. Huestis M.D.
Address
1019 Wicker Street, Ticonderoga, NY 12883
Death Certificate Filed Town of District Number Register Number
City, Town or Village Ticonderoga 1 564 <Y0
DBurial Date Cemetery or Crematory •
05/26/2015 Pine View Crematory
DEntombment Address
®Cremation Queensbury, New York
Date Place Removed
Z❑Removal and/or Held
and/or Address
= Hold
cn
O Date Point of
IL Q Transportation Shipment
in
1 by Common Destination
iiigi Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
m LiPermit Issued to Registrai.ot? Number
Name of Funeral Home Wilcox & Regan funeral home
ip! Address
W11 Algonkin St. , Ticonderoga, NY 12883
Name of Funeral Firm Making Disposition or to Whom
.10. Remains are Shipped, If Other than Above
• Address
til
' Permission is hereby granted to dispose of the human rem ' described above - dicated.
Date Issued 0 5/2 2/2 01 5 Registrar of Vital Statistics 'IN-\,\c-Ditrv—
\(\.1.� (sign )
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:
pDispositionl) Cr... vktml
tl�• Date of Disposition SiS�z1If6' Place of ,t'n
2 (address)
LU
CC (section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises 1 ; S
Z / (please print)
W. Signature 6-(. �9 Title eRCitiKit
(over)
DOH-1555 (02/2004)