Breiseth, Jane NEW YORK STATE DEPARTMENT OF HEALTH v , 2 # IL
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Jane Morhouse Breiseth Female
Date of Death Age If Veteran of U.S. Armed Forces,
6/16/2012 72 yrs. War or Dates No
- Place of Death Town of Hospital, Institution or
City, Town or Village Ticonderoga Street Address 428 Black Point Road
Manner of Death Natural Cause ❑Accident ❑Homicide El Suicide 0 Undetermined Pending
W Circumstances Investigation
iii Medical Certifier Name Title
1 Glen Chapman M.D.
Address
P.O. Box 29, Ticonderoga, New York 12883
:a Death Certificate Filed Town of District Number Register Number
City, Town or Village ,Ticonderoga 1 564 34
0 Burial Date Cemetery or Crematory
06/19/2012 Pine View Crematory
❑Entombment Address
i ®Cremation Queensbury, New York
Date Place Removed
Z❑Removal and/or Held
C and/or Address
k=` Hold
CA
0 Date Point of
t Transportation Shipment
ciby Common Destination
Carrier
❑Disinterment Date Cemetery Address
gii❑Reinterment Date Cemetery Address
in Permit Issued to Registration Number
Name of Funeral Home Wilcox & Regan funeral home 01821
'»' Address
11 Algonkin St. , Ticonderoga, New York 1 2883
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
t
w
Permission is hereby granted to dispose of the human re ains described above as indicated.
Date Issued 6/1 8/2 0 1 2 Registrar of Vital Statistics °
(signature)
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:
t /�
f Date of Disposition chi In, Place of Disposition 4r,,i Utru] Crrwwt6ou..,
(address)
iii
i*
VC (section) 4 (lot number) (grave number)
0
Name of Sexton or Person in C arge of Premises S",44t
(pl ase print)
Signature rik Title CiteMt4T0G
(over)
DOH-1555 (02/2004)