Denton, Martha NEW YORK STATE DEPARTMENT OF HEALTH - (oI
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Martha J. Denton Female
Date of Death Age If Veteran of U.S. Armed Forces,
09/21 /201 4 71 yrs_ War or Dates No
I-- Place of Death Town of Hospital, Institution or Heritage Commons
WCity, Town or Village Ticonderoga Street Address Residential Healthcare
p Manner of Death Natural Cause El Accident 0 Homicide 0 Suicide 0 Undetermined 0 Pending
W Circumstances Investigation
W Medical Certifier Name Title
G Kathleen A. Huestis M.D.
Address
102 Racetrack Road, Ticonderoga, NY 12883
Death Certificate Filed Town of District Number Register Number
City, Town or Village Ticonderoga 1 564 47
❑Burial Date Cemetery or Crematory
QEntombment 2014 Pine View Crematory
Address
®Cremation Queensbury, New York
Date Place Removed
Z Removal and/or Held
0❑and/or
.., Address
• Hold
0 Date Point of
�" Transportation Shipment
0 by Common Destination
Carrier _
Q Disinterment Date Cemetery Address
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
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
lif
a' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 09/2 3/201 4 Registrar of Vital Statistics a.,,,, , • `,,.-t -
/ (signature)
iii 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 �
ill Date of Disposition 101II i Place of Disposition _f�.tt)rtJ rcwiojl,t.-
2 (address)
U
tia
(section) r er(lot numb (grave number)
p Name of Sexton or Person in Charge of Premises r.il a'►''l0
lease print)
Signature64+ Title c'itt. it
(over)
DOH-1555 (02/2004)