Poole, Helen NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Helen D. Pnn1P PPma1P
Date of Death Age If Veteran of U.S. Armed Forces,
T. 9/26/2014 92 yrs. War or Dates No
Place of Death Town of Hospital, Institution or Heritage Commons
J City, Town or Village Ti ndero a Street Address Residential Healthcare
W Manner of Death®Natural Cause 11 Accident Homicide 0 Suicide Undetermined Pening
Circumstances Investigation
W Medical Certifier Name Title
G Glen Chapman M D
Address
P.O. Box 29, Ticonderoga, New York 12883
Death Certificate Filed Town of District Number Register Number
City, Town or Village Ticonderoga 1 564 4R
El Burial Date Cemetery or Crematory
10/01 /2014 Pine View Crematory
❑Entombment Address
®Cremation Queensbury, New York
Date Place Removed
Pl ❑Removal and/or Held
and/or
FR Hold Address
,T
0 Date Point of
11` Transportation
-CO ❑ Shipment
0 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, New York 12883
Name of Funeral Firm Making Disposition or to Whom
F Remains are Shipped, If Other than Above
2 Address
Cr
Ili
Permission is hereby granted to dispose of the human rem ins described above as indicated.
Date Issued 09/29/201 4 Registrar of Vital Statistics ,4. J `yY-) . C i�_„--_.
(signature)
i< 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 j
ILI Date of Disposition 1013114 Place of Disposition gU.4J c,,.v,ro,,,,,
Ili (address)
F/
(section)
(lot n ber) (grave number)
Ct Name of Sexton or Person in Charge of Premises 4r,> .. , 1
z 1� ( lease print)
Signature {r!.- Title asM 'f64-
(over)
DOH-1555 (02/2004)
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