Salstead, Constance it
NEW YORK STATE DEPARTMENT OF HEALTH V v
Vital Records Section ` - ' Burial - Transit Permit
Name First Middle Last Sex
Constance E. Salstead Female
Date of Death Age If Veteran of U.S. Armed Forces,
08/09/2013 90 yrs. War or Dates No
,.: Place of Death Town of Hospital, Institution or
untZ City, Town or Village Ticonderoga Street Address Moses-Ludington Adult Home
II Manner of Death m=Natural Cause El Accident 0 Homicide Ei Suicide riUndetermined 0 Pending
tU Circumstances Investigation
W Medical Certifier Name Title
0 Todd R. Waldorf D.O.
Address
1019 Wicker Street, Ticonderoga, New York 12883
Death Certificate Filed Town of District Number Register Number
City, Town or Village Ticonderoga 1 564 54
i < ❑Burial Date Cemetery or Crematory
❑Entombment 08/14/2013 Pine View Crematory
Address
;` OCremation Queensbury, New York
Date Place Removed
Z ri❑Removal and/or Held
and/or Address
— Hold
1)
0 Date Point of
Ili 0 Transportation Shipment
a by Common Destination
Carrier •
Q Disinterment Date Cemetery Address
SiiiQ Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Wilcox & Regan Funeral Home 54
Address
liki 11 Algonkin St. , Ticonderoga, New YOrk 12883
Ilp Name of Funeral Firm Making Disposition or to Whom .
Remains are Shipped, If Other than Above
,2 Address
CC
111
'` Permission is hereby granted to dispose of the human remai s escribed ove as i "cated.
iiN Date Issued 0 8/1 2/201 3 Registrar of Vital Statistics
(sin re)
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:
2
Ill Date of Disposition thOlp Place of Disposition emouo w tal46-
(address)
1U
CA
(section) lot number) (grave number)
Name of Sexton or Perso in Charge of P emises �� "��
f (plea print)
Signature „/,J/� Titler (1 ..
(over)
DOH-1555 (02/2004)