Whitty, Shirley x N a
NEW YORK STATE DEPARTMENT OF HEALTH L 15
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Shirley S_ Whitty Female
Date of Death Age If Veteran of U.S. Armed Forces,
04/06/2013 85 yrs. War or Dates No
} Place of Death Town of Hospital, Institution or
City, Town or Village Ticonderoga Street Address 8 Park Avenue
illW Manner of Death Natural Cause 0 Accident 0 Homicide 0 Suicide Undetermined Pending
Circumstances Investigation
tit Medical Certifier Name Title
Glen Chapman M.D.
Address
P.O. Box 29, Ticonderoga, NY 12883
Death Certificate Filed Town of District Number Register Number
City, Town or Village Ticonderoga 1 564 24
❑Burial Date Cemetery or Crematory
04/12/2013 Pine View Crematory
i;0 Entombment Address
®Cremation Queensbury, New York
Date Place Removed
Removal and/or Held
and/or
M;;;;; Address
Hold
0 Date Point of
inigL Q Transportation Shipment
0 by Common Destination .
Ai Carrier
Q Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
is> 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
Or
t
"' Permission is hereby granted to dispose of the human re ai s describe b ve a •dicated.
Date Issued 04/0 4/201 3 Registrar of Vital Statistics \ 1 fie a t
(sign-
10 District Number 1 564 Place Town of Ticon roga
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
IU Date of Disposition LI"(12—(3 Place of Disposition -{�,rt,(,L (,r�"�1,,elaAu-,
2 (address)
fil
VI
ct (section) (lot number) (grave number)
a
ci Name of Sexton or Person in Charge f Premises di,IiiLL... _�tiw t
I ( ase print)
Signature l�— Title CO EItifiT3(.
(over)
DOH-1555 (02/2004)