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Alteri, Nina NEW YORK STATE DEPARTMENT OF HEALTH tt S Vital Records Section - , Burial - Transit10i ermit Name First Middle Last Sex Nina Marie Alteri Female Date of Death Age If Veteran of U.S. Armed Forces, 10/19/2012 47 yrs. War or Dates No 1- Place of Death Town of Hospital, Institution or Z City, Town or Village Ticonderoga Street Address Moses-Ludington Hospital itlri Manner of Death Undetermined Pending ©Natural Cause ❑Accident ❑Homicide ❑Suicide ILI ❑ ❑ Circumstances Investigation ta Medical Certifier Name Title G C. Francis Varga M.D. Address P.O. Box 768, Lake Placid, NY 12946 Death Certificate Filed Town of District Number Register Number City, Town or Village Ticonderoga 1 564 Q ❑Burial Date Cemetery or Crematory ['Entombment Pine View Crematory Address ®Cremation Queensbury, New York Date Place Removed "g❑Removal and/or Held — and/or Address M= Hold IA O Date Point of Transportation Shipment Cs by Common Destination Carrier ❑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 • Address ILI Permission is hereby granted to dispose of the human remains de ribed abov as incl. ted. Date Issued 1 0/2 2/201 2 Registrar of Vital Statistics Mi (signatu District Number 1 564 Place Town of Ticonderoga I certify that the remains of the decedent identified above were disposed of iYn,accordance with this permit on: lit z '( V cc>'rrrctor t�,� Date of Disposition �O-Z�-t Place of Disposition ,p�, ,.ems W (address) fil CC (section) (lot number) (grave number) O.0 Name of Sexton or Person in Charge of remises 40; sQ ,l 41 ( lease print) • Signature Title C121 MAtg (over) DOH-1555 (02/2004)