Hurlburt, Beatrice NEW YORK STATE DEPARTMENT OF HEALTH ' Ir kc
Vital Records Section Burial - Transit Perm
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Name First Middle Last Sex
Bea_tri ce DI_ Hurlburt Female
Date of Death Age If Veteran of U.S. Armed Forces,
0 2/2 2/2 014 8-6 y„. War or Dates No
Place of Death Town of Hospital, Institution or
Heritage Commons
City, Town or Village Ti cnndprnga Street Address Residential Healthcare
ct Manner of Death 0 Natural Cause 0 Accident 0 Homicide Ei Suicide ❑Undetermined ri Pending
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Circumstances Investigation
w Medical Certifier Name Title
Todd R. Waldorf D.,0,
Address -
1019 Wicker Street, Ticonderoga, NY 12883
Death Certificate Filed Town of District Number Register Number
City, Town or Village Tirmuiproga 1 c64 q
DBurial Date Cemetery or Crematory
02/25/2014 Pine View Crematory
❑Entombment Address
``> remation Queensbury, New York
Date Place Removed
Removal and/or Held
Q:
.,. and/or Address
H Hold
Eli
0 Date Point of
to Li Transportation Shipment
G3 by Common Destination
Carrier
Q Disinterment Date Cemetery Address
M. Q 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
41 Name of Funeral Firm Making Disposition or to Whom
100 Remains are Shipped, If Other than Above
Address
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Permission is hereby granted to dispose of the human remai s described above as indicated.
Date Issued 0 2/2 5/2 01 4 Registrar of Vital Statistics : a—/- __4e-/
(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:
2
iii Date of Disposition a h thy Place of Disposition ?;.r111,t, rez pt.--
2 (address)
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CO
CC (section) /� (lot number) (grave number)
0 Name of Sexton or Person "n Charge of Premises r,l (. htjrir
' lease print)
W.
Signature Title G f'+4-P►2
(over)
DOH-1555 (02/2004)
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