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Welss, Irmgard NEW YORK STATE DEPARTMENT OF HEALTH° - I 3 Vital Records Section Burial - Transit a mit Name First Middle Last Sex Irmgard Anne Weiss Female Date of Death Age If Veteran of U.S. Armed Forces, June 14, 2013 81 yrs. War or Dates No 1- Place of Death Town of Hospital, Institution or Zuj City, Town or Village Hague Street Address 9593 Lake Shore Drive 0 Manner of Death®Natural Cause ❑Accident ❑Homicide ❑Suicide 0 Undetermined ❑Pending ILL Circumstances Investigation W Medical Certifier Name Title CI William F. Orluk RPA-C Address 268 Darrensville Road, Chestertown, NY 12817 Death Certificate Filed Town of District Number Register Nui ber City, Town or Village Hague 5653 lU ['Burial Date Cemetery or Crematory ['Entombment Pine View Crematory Address ©Cremation Queensbury, New York Date Place Removed " ❑Removal and/or Held and/or Address E F Hold U) 0 Date Point of iri❑Transportation Shipment Q by Common Destination Carrier >` ❑Disinterment Date Cemetery Address ❑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 1 Remains are Shipped, If Other than Above Address Z (U Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 06/1 7/201 3 Registrar of Vital Statistic f1 1 signature District Number 5653 Place Town of Hague I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: k �/ /+ I Date of Disposition (b i i' P Place of Disposition "►-.A., C•tr►tliorai.r... (address) !i tfl CC (section) Acitfil2r (lot number) . (grave number) Name of Sexton or Perso in Charge of remises e ,ibl'2 (p1se print) 410 Signature 7L Title l:r7J 1ifrue (over) DOH-1555 (02/2004)