Slater, Jennie NEW YORK STATE DEPARTMENT OF HEALTH �I it CV /
Vital Records SectionBurial - Transit Permit
Name First Middle Last Sex
Jennie Lou Slater Female
Date of Death Age If Veteran of U.S. Armed Forces,
09/18/2014 66 yrs. War or Dates No
• Place of Death Town of Hospital, Institution or
WCity, Town or Village Ticonderoga Street Address 105 Cossey Street
W▪ Manner of Death g Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
O Circumstances Investigation
W Medical Certifier Name Title
C C. Francis Varga M.D.
Address
P.O. Box 768, Lake Placid, NY 12946
Death Certificate Filed Town of District Number Register Number
City, Town or Village Ticonderoga 1 564
❑Burial Date Cemetery or Crematory
❑Entombment 09/22/2014 Pine View Crematory
Address
X❑Cremation Queensbury, New York
ZDate Place Removed
Removal and/or Held
..,. and/or Address
H Hold
Cil
O Date Point of
coCli❑Transportation Shipment
O 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, NY 12883
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
g Address
tr
to
II` Permission is hereby granted to dispose of the human remains s ibed above indi .
Date Issued 9-01/,a 0)VRegistrar of Vital Statistics
•
(signatur
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:
Z ILI Date of Disposition 9Jz3Jrj Place of Disposition l(`ra,�.t-, errK44z;..�
1 (address)
V/
E (section) / (lot number) (grave number)
OName of Sexton or Person in Charge of Premises Lair.. .,�i�, Q
z 41✓ (ease pnnt)
• Signature '�- lam' Title (iZe►fit ;c
(over)
DOH-1555 (02/2004)