Blood, Rose I it ft i(3
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Rose Marie Bloc. Female
Date of Death Age If Veteran of U.S. Arme orces,
03/04/2014 95 yrs. War or Dates No
1- Place of Death Town of Hospital, Institution or
Z City, Town or Village Putnam Station Street Address 1 04 County Rte. 2
iiiManner of Death®Natural Cause 0 Accident 0 Homicide 0 Suicide El Undetermined Pending
Ut Circumstances Investigation
ui▪ Medical Certifier Name Title
G Richard McKeever M.D.
Address
102 Race Track Road, Ticonderoga, NY 12883
, Death Certificate Filed Town of District Number Register Number
City, Town or Village Ticonderoga 5763 2
DBurial Date Cemetery or Crematory
Wu
Entombmenf 03/10/2014 Pine View Crematory
Address
-n®Cremation Queensbury, New York
Date Place Removed
Z Removal and/or Held
9❑and/or
- Hold Address
in
O Date Point of
n
t Transportation Shipment
5 by Common Destination
Carrier
Q Disinterment Date Cemetery Address •
Q Reinterment Date Cemetery Address
iiiii •
Permit Issued to Registration Number
Name of Funeral Home Wilcox & Regan funeral home 01 821
Address
11 Algonkin St. , Ticonderoga, NY 12883
ig Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
', Address
cr.
ILI
P` Permission is hereby granted to dispose of the human remains described above as indicated.
iiE Date Issued 03/0 6/201 4Registrar of Vital Statistics C( ci,y\i,,p �
� k_CAU
�- (sighature)
District Number 5763 Place Town of Putnam Station
al
I certify that the remains of the decedent identified above wer disposed of in accordance with this permit on:
ILI Date of Disposition �/Z/ Place of Disposition 1/?/,2- V�tr/
(Ck,,,fridadef
ss)
til
1Z (section) (lot number) (grave number)
iti Name of Sexton r on in Charge of Premises (please print)
• Signature ' Title ( r F/J��
(over)
DOH-1555 (02/2004)