Delong, Josephine ‘7. it )5k
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Josephine per, n Female
Date of Death Age If Veteran of U.S. Armed Forces,
May 1 0, 201 4 82 yrs. War or Dates No
14. Place of Death Town of Hospital, Institution or
ii City, Town or Village Ticonderoga Street Address 79 Lord Howe Street
0 Manner of Death®Natural Cause El Accident El Homicide El Suicide riUndetermined Pending
tij Circumstances Investigation
' Medical Certifier Name Title
C— Francis Varga M.D.
Address
P.O. Box 768, T,akP Placid, NY 12946
Death Certificate Filed Town of . District Number Register Number
City, Town or Village Ticonderoga 1 5 6 4 2 4
.—,,---,Burial Date Cemetery or Crematory
'[]Entombment 05/1 3/201 4 Pine View Crematory
Address
: : @Cremation Queensbury, New York
Date Place Removed
❑Removal and/or Held
2 and/or Address
t: Hold
tom.
Q Date Point of
la Q Transportation Shipment
et by Common Destination
MI Carrier
Q 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
• Address
tr
w
"` Permission is hereby granted to dispose of the human remains described above asrr indicated.
'' Date Issued 0 5/1 2/201 4 Registrar of Vital Statistics / / /)2 ' Gu���,/L�'
(signature)
ii 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:
l.,Place of Disposition e (. �.
▪ Date of Disposition ��'l3-l`I p (address)
ill
It (section) (lot number) it
(grave number)
• Name of Sexton or Per n in Charge f Premises , �i"'�Y
Z ( lease print)
. i Title t ^ATIO!
• Signature
(over)
DOH-1555 (02/2004)