Davidson, Erika NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Erika Davidson Female
Date of Death Age If Veteran of U.S. Armed Forces,
1 1 /1 9/201 4 4 2 years War or Dates No
l- Place of Death Town of Hospital, Institution or
ZCity, Town or Village Ticonderoga Street Address Moses-Ludington Hospital
W Manner of Death a Natural Cause 0 Accident 0 Homicide Suicide 0 Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
0 C. F. Varga M.D.
Address
P.O. Box 768, Lake Placid, NY 12946
Death Certificate Filed Town of District Number Register Number
City, Town or Village Tironrd,rnga 1 964 60
I ; El Burial Date Cemetery or Crematory
❑Entombment 11 /24/2014 Pi nP View Crematory
Address
®Cremation Oo1 nGbury, New York
(Sate Place Removed
Z❑Removal and/or Held
H and/or Address
Cl) Hold
0 Date Point of
CI.
Q Transportation Shipment
C by Common Destination
Carrier
El Disinterment Date Cemetery Address
QReinterment 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
1 Remains are Shipped, If Other than Above
Address
tr
la
d' Permission is hereby granted to dispose of the human re ains described above as indicated.
Date Issued 1 1 /21 /2 01 4 Registrar of Vital Statistics i L t / , .1(t„��
/ (signature)
District Number 1 564 Place Town of Ticonderoga
1 I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z L
ti Date of Disposition fl/1t�ty Place of Disposition ern, Vt..,, Cr ,r.�
(address)
111
l (section) (lot num(be') (grave number)
Ct
CI Name of Sexton or Person in Charge of Premises t 1,40
z 'please print)
tit Signature7 Title Ut O ,,
(over)
DOH-1 555 (02/2004)