Peters, Esther # ilNEW YORK STATE ui:.72-t>RTMENT OF HEALTH vl i
Vital Records Section it Burial - Transit Permit
Name First Middle Last Sex
Esther B. Peters Female
b. Date of Death Age If Veteran of U.S. Armed Forces,
08/02/2013 93 yrs. , War or Dates No
t Place of Death Town of Hospital, Institution or Heritage Commons
WCity, Town or Village Ticonderoga Street Address Residential Healthcare
O Manner of Death Natural Cause Accident Homicide Suicide Undetermined 0 Pending
III) Circumstances Investigation
ui▪ Medical Certifier Name Title
CI
Toni M. Strum M_D_
Address
1019 Wicker st Ticonderoga N.Y. 12853
Death Certificate Filed Town of District Number Register Nymr
City, Town or Village Ticonderoga 1 564 9 ��
['Burial Date Cemeteryor Crematory
08/05/2013 Pine View Crematory
in❑Entombment Address
['Cremation Queensbury, New York
Date Place Removed
❑Removal and/or Held
and/or
Iwo* Address
CO
Hold
0 Date Point of
uy Li Transportation Shipment
0 by Common Destination
Carrier
El Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Wilcox & Regan funeral home 01 821
Address •
Nii 11 Algonkin St. , Ticonderoga, NY 12883
iqii Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
i
i
P`` Permission is hereby granted to dispose of the human r ains described above as indicated.
Date Issued 08/05/2013 Registrar of Vital Statistics ' in . d
(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:
ILI Date of Disposition $16113 Place of Disposition /, t,k„J etiy,c{pN„
(address)
ill
U)
CC (section) (lot number) (grave number)
tt Name of Sexton or Perso in Charge of Premises /hi i s+ r Snati
Z► ( lease print)
Ui
Signature Title CaCiMi 6OL
(over)
DOH-1555 (02/2004)