Ryan, Brenda s NI � 05
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name first Middle st Sex
ni' a L--`2`2 lt1
Date of Death Age If Veteran of U.S. Armed Forces,
G a) i i q 55 yrs_ War or Dates No
Place of Death Town of Hospital, Institution or
W City, Town or Village Moriah Street Address 7 McMurtry Way, Minevi l le
Manner of Death 6..9 Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
111 Circumstances Investigation
:j Medical Certifier Name Title
12 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 Moriah 1 558
❑Burial Date Cemetery or Crematory
1-1 0 3/0 4/2 01 4 Pine View Crematory
❑Entombment Address
®Cremation Queensbury, New York
Date Place Removed
Z❑Removal and/or Held
and/or Address
- Hold
ID
O Date Point of
n 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
2 Address
LU
IIL. Permission is hereb granted to dispose of the human remains described above as indicated.
Date Issued Rh 7/ °y Registrar of Vital Statistics ___�4 L.
(signature)
District Number 1,5 5 Place 0., -.��..e (A (
li
" I certify that the remains of the decedent identified above were di posed of in accordance with this permit on:
ILI• Date of Disposition 3�4i IIq Place of Disposition C. ,„„_
2 (address)
W.
(section) (lot number,,)— (grave number)
Name of Sexton or Per n in Cha ge of Premises di*, .ixr/r
► ease print)
Signature A Title Nr i2
g
(over)
DOH-1555 (02/2004)