O'Connor, Mary NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Mary C- n'CDnnor FPmale
Date of Death Age If Veteran of U.S. Armed Forces,
1 0/05/201 4 86 yrs_ War or Dates No
} ? Place of Death Town of Hospital, Institution or
' City, Town or Village Ti cnndQroga Street Address Moses-Ludington Hospital
Ci: Manner of Death®Natural Cause D Accident El Homicide 0 Suicide riUndetermined ri Pending
Circumstances Investigation
tit Medical Certifier Name Title
Kathleen 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 51
> < El Burial Date Cemetery or Crematory
<'iiQEntombment 10/10/2014 Pine View Crematory
Address
®Cremation Queensbury, New York
Date Place Removed
2❑Removal and/or Held
and/or
F;;; Address
CO
Hold
C> Date Point of
tca L Transportation Shipment
C by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Q Renterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Wilcox & Regan funeral home 51
Address
11 Algonkin St. , Ticonderoga, NY 12883
Name of Funeral Firm Making Disposition or to Whom
14 Remains are Shipped, If Other than Above
2 Address
CC
III
IL
Permission is hereby granted to dispose of the human remai escribed ve a i •icated.
Date Issued 1 0/8/201 4 Registrar of Vital Statistics
sig f ature)
District Number 1 564 Place Town of Ticon rog
;.;:
I certifythat the remains of the decedent identified above were disposed of in accordance with this permit on:
1-- ,,//
Ill Date of Disposition fc j is-1 i Place of Disposition tL, 6:01,4for'v-
2 (address)
w
to
r (section) (lot number) (grave number)
�SE,�
0 Name of Sexton or Person in Charge of Premises 4%1- /ease print) tt
Signature 6 2Title C/4 OM
(over)
DOH-1555 (02/2004)