Williams, Monique NEW YORK STATE DEPARTMENT OF HEALTH t ,,_.., 1 tk (63
Vital Records Section Burial - Transit Permit
gi Name First Middle Last Sex
Monique D. Williams Female
Date of Death Age If Veteran of U.S. Armed Forces,
February 21 , 201 3 78 yrs. War or Dates No
I. Place of Death Town of Hospital, Institution or Heritage Commons
City, Town or Village Ticonderoga Street Address Residential Healthcare
Manner of Death 0 Natural Cause 0 Accident El Homicide 0 Suicide ri Undetermined ri Pending
Circumstances Investigation
in Medical Certifier Name Title
iQ Todd R. Waldorf D.O.
Address
1019 Wicker Street, Ticonderoga, NY 12883
Death Certificate Filed Town of District Number Register Number
City, Town or Village Ticonderoga 1 564 1 5
Hi['Burial Date Cemetery or Crematory
2/25/2013 Pine View Crematory
iin['Entombment Address
kCremation Queensbury, New York
Date Place Removed
gRemoval and/or Held
0.0 El and/or Address •
Hold
Date Point of
11 0 Transportation Shipment
a by Common Destination
imi Carrier
gii
Q Disinterment Date Cemetery Address
Reinterment Date• Cemetery Address
0 LiRH 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
I
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d" Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 2/24/201 3 Registrar of Vital Statistics � ,l ez., 7�'} -a�.���
(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:
III• Date of Disposition 7.-17-13 Place of Disposition RJJj Ce iw_
2 (address)
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C
CC (section) , (lot number) (grave number)
CI Name of Sexton or Person in Charge o Premises 4r. Lt_ £.4t
ear (please print)
Signature r
`CILI - Title Cw► �Q.
(over)
DOH-1555 (02/2004)