Varmette, Juanita NEW YORK STATE DEPARTMENT OF HEALTH #
Vital Records Section ,. Burial - Transit Permit
Name First Middle Last Sex
Juanita M._ Varmette Female
Date of Death Age If Veteran of U.S. Armed Forces,
12/07/2014 90 yrs. War or Dates No
1 - Place of Death Town of Hospital, Institution or
laCity, Town or Village Ticonderoga Street Address 1 45 Lord Howe Street
0 Manner of Death Ea Natural Cause El Accident ❑Homicide El Suicide El Undetermined 0 Pending
ILI Circumstances Investigation
ILI Medical Certifier Name Title
C. Francis Varga M.D.
Address
P_O_ Box 76R, T,akp Placid, NY 12946
Death Certificate Filed Town of District Number Register Number
City, Town or Village Ti rnndPrnga 1 564
n. ❑Burial Date Cemetery or Crematory
❑Entombment 12/09/201Address 4 Pine View Crematory
PR®Cremation Oueensbury, Ny
Date Place Removed
Removal and/or Held
El and/or Address
I:: Hold
0 Date Point of
Transportation Shipment
Ct 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
!iPii Address
11 Algonkin St. Ticonderoga, NY 12883
r Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
a Address
IX
ILI
IL
Permission is hereby granted to dispose of the human re in descri boy- .- i dicated.
Date Issued 1 2/9/2 1 4. Registrar of Vital Statistics .
sig =ture)
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:
ILI Date of Disposition il/lolitc Place of Disposition 1'.40,1..) C 'ot .-
2 (address)
La
fil
CC (section) (Iqt number) E (grave number)
Name of Sexton or Person in Charge of Premises �n,tr. Jeri
2Ir /fir (pie se print)
iii Signature L I J i Title (t€mho.
(over)
DOH-1555 (02/2004)