Sage, Gladys NEW YORK STATE DEPARTMENT OF HEALTH• ' 5
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
(;] adys M Sage Female
Date of Death Age If Veteran of U.S. Armed Forces,
1 7/11 /2 01 3 9 4 yr s_ War or Dates No
}• Place of Death Town of Hospital, Institution or
City, Town or Village Heritage Commons
9 Ti condProga Street Address Residential Healthcare
Manner of Death Natural Cause El Accident 0 Homicide El Suicide EjUndetermined ri Pending
tti
Circumstances Investigation
tu Medical Certifier Name Title
Q Kathleen Huestis M.D.
Address
1 01 9 Wicker Street, Ticonderoga, NY 12883
Death Certificate Filed Town of District Number Register Number
City, Town or Village Ticonderoga 1 564 85
`i 0 Burial Date Cemetery or Crematory
i Entombment 01 /03/201 3 Pine View Crematory
Address
;'®Cremation Queensbury, New York
Date Place Removed
Z Removal and/or Held
.9❑and/or Address
F* Hold
CA
a Date Point of
Transportation L. p Shipment
0 by Common Destination
Mi Carrier
Q Disinterment Date Cemetery Address
1-_-_]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
I
It
fl"' Permission is hereby granted to dispose of the human re ains described above as indicated.
Date Issued 01 /0 2/201 4 Registrar of Vital Statistics yy) .
(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:
k
ILI Date of Disposition I/1((°1 Place of Disposition .7i.
t tV 641.413*st.r.
a (address)
Ui
Mt
I (section) t number) (grave number)
3 Name of Sexton or Person in harge of P emises ns- b- Stw0.Ct
(plea a print)
Signature c L Title L W?if tU -
l (over)
DOH-1555 (02/2004)