Breitenbach, Janet NEW YORK STATE DEPARTMENT OF HEALTI-4 4 ti( '
Vital Records Section Burial - Transit Permit
Name First Middle Last 1 Sex
Janet Louise Breitenbach 1 Female
:> Date of Death Age If Veteran of U.S. Armed Forces.
April 1 1 , 2014 1 86 yrs.' • War or Dates No
>E Place of Death Town of 1 Hospital, Institution or 22 Delaware Ave. ,
>Z City, Town or Village Hague 1 Street Address Silver Bay
iManner of Death X Natural Cause n Accident n Homicide Suicide Undetermined El Pending
W —Circumstances Investigation
Medical Certifier Name Title
ALI
0 Glen Chapman M.D.
Address
102 Race Track Road, Ticonderoga, NY 12883
iNi Death Certificate Filed Town of District Number Register Number
City, Town or Village Hague 5653
Date Cemetery or Crematory
(Burial 04/15/2014 1 Pine View Crematory
Address
❑X Cremation Queensbury, New York
Date Place Removed
— Removal and/or Held
' —and/or Address
NHold
0 Date Point of
ai n Transportation Shipment
G by Common Destination
Carrier
Disinterment Date Cemetery Address
n 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 128
'? Name of Funeral Firm Making Disposition or to Whom
::ice:" Remains are Shipped, If Other than Above
aAddress
LU
ly
Permission is hereby granted to dispose of the human ains described above as indicated. •
iM Date Issued 04/1 4/2 01 4 Registrar of Vital Statistic` . $)..r,„;:y-,-.01..L.s.`"---4 . ' n n i le\ '
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District Number 5653 Place Town of Hag
I certify that the remains of the decedent identified above WE 'isposed of in accordance with this permit on:
it-
WDate of Disposition u'IS' if Place of Disposition - (41)414...; awfitw-,
2 (adc 3)
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(I)
CC (section) (lot numb (grave number)
G Name of Sexton or Pe on in Ch ge of Premises g..
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Z (please )
Signature L T (0 +'I
(over)
DOH-1555 (9/98)