Andrus, Ethel 4. . It Lt7
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
ETHEL ANN ANDRUS Female
Date of Death Age If Veteran of U.S. Armed Forces,
0 9/1 4/2 01 2 91 yr s. War or Dates No
• Place of Death Town of Hospital, Institution or Heritage Commons
2 City, Town or Village Ticonderogatki Street Address Residential Healthcare
• Manner of Death Undetermined Pending
Natural Cause El ❑Homicide ❑Suicide ❑ ❑
IUD Circumstances Investigation
tu Medical Certifier Name Title
O Glen Chapman M.D.
Address
P.O. Box 29, Ticonderoga, New York 12883
Death Certificate Filed Town of District Number Register Number
City, Town or Village Ticonderoga 1 564 56
❑Burial Date Cemetery or Crematory
09/17/2012 Pine View Crematory
❑Entombment Address
`®Cremation Queensbury, New York
Date Place Removed
❑and/or
Removal and/or Held
� Address;
0
Hold
0 Date Point of
❑Transportation Shipment
Gt 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
11 Algonkin St. , Ticonderoga, New York 12883
Name of Funeral Firm Making Disposition or to Whom
▪ Remains are Shipped, If Other than Above
a Address
CC
ILi
Permission is hereby granted to dispose of the human r ains described above as indicated.
Date Issued 09/1 4/201 2 Registrar of Vital Statistics
T�
(signature)
District Number 1 564 Place Town of Tic nderoga
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k
LEI Date of Disposition q-i1-11 Place of Disposition ?1,1Uuw `i+-13 riU�.
2 (address)
Lu
CO
CC (section) 4 (lot number) (grave number)
Name of Sexton or Person in Chargeof Premises L INIJ5*, �N..f
-11
2 (please print)
Signature Title aciiiek..0t
(over)
DOH-1555 (02/2004)