Thelen, Virginia NEW YORK STATE DEPARTMENT OF HEALT3-i i a 4 1 Z
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Virginia T,_ Thelen Female
Date of Death Age If Veteran of U.S. Armed Forces,
3/,31 /2013 92 yrs. War or Dates No
F- Place of Death Town of Hospital, Institution or Her ita a Commons
Z City, Town or Villagelij Ticonderoga Street Address Residential Healthcare
a Manner of Death ix_ Natural Cause 0 Accident 0 Homicide 0 Suicide 0Undetermined ri Pending
10 Circumstances Investigation
Medical Certifier Name Title
Todd R. Waldorf n_0_
Address
1019 Wicker Street., Ticonderoga, NY 1288?
Death Certificate Filed Town of District Number Register Number
City, Town or Village Ticonderoga 1 564
.::,gi 0 Burial Date Cemetery or Crematory
Entombment 201 3 Pine View Crematory
Address
®Cremation Queensbury, New York
Date Place Removed
Z El Removal and/or Held
2 and/or Address
Hold
Date Point of
�t
Transportation Shipment
G 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
t
Ili
Permission is hereby granted to dispose of the human remain escribed ab e as in . ted.
Date Issued 0 4/01 /2 01 3 Registrar of Vital Statistics I; 60~--
(sign tur )
District Number 1 564 Place Town of Ticonderoga
1 I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z �
1 Date of Disposition q- 213 Place of Disposition ��U .) a17+'iii,`
a (address)
UI
t
r (section) (lot number) f (grave number)
Name of Sexton or Person in Charge of Premises ` tgJ{ '- 6,4
r (pie se print)
} Signature Title CTatvhcFo ,
(over)
DOH-1555 (02/2004)