White, Carolyn NEW YORK STATE DEPARTMENT OF HEALTH ' ' -
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Carolyn Beatrice white Female
Date of Death Age If Veteran of U.S. Armed Forces,
1 1 /1 4/201 3 88 yrs. War or Dates No
M- Place of Death Town of Hospital, Institution or
2 City,
` Town or Village Ticonderoga Street Address 9 Woody Lane
.. Manner of Death 0 Natural Cause 0 Accident 0 Homicide ElSuicide �Undetermined El Pending
Mt Circumstances Investigation
01
ui Medical Certifier Name Title
O 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
❑Burial Date Cemetery or Crematory
11 /15/2013 Pine View Crematory
❑Entombment Address
!;`@Cremation Queensbury, New York
Date Place Removed
Ac❑Removal and/or Held
and/or Address
�=` Hold
Cl)
O Date Point of
itL
Q Transportation Shipment
C by Common Destination
Carrier
Q Disinterment Date Cemetery Address
!; Q 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 12883
- Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
• Address
l
` Permission is hereby granted to dispose of the human re ains described above as indicated.
Date Issued 1 1 /1 5/201 3 Registrar of Vital Statistics in • t t -ram
(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:
til• Date of Disposition II/NIB Place of Disposition P (�1V 6 04t,-
a (address)
tLt
to
is (section) /fpot number) (grave number)
iti Name of Sexton or Person in harge of P, emises ( ht4A "�{f
z (plea print)
Signature IL Title CwirpX
(over)
DOH-1555 (02/2004)