Wallace, Rosemary NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
is Name First Middle Last Sex
Rosemary D. Wallace Female
Date of Death Age If Veteran of U.S. Armed Forces,
0 9/0 2/2012 75 yrs. War or Dates No
14 Place of Death Town of Hospital, Institution or
City, Town or Village Ticonderoga Street Address 1 9 Woody Lane
G1k Manner of Death Natural Cause ❑Accident ❑Homicide ❑Suicide ri❑Undetermined 1-1❑Pending
l Circumstances Investigation
iii Medical Certifier Name Title
C 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 S I
<; ❑Burial Date Cemetery or Crematory
['Entombment Address
Pine View Crematory
ai Address
iii ®Cremation Queensbury, New York
Date Place Removed
9❑Removal and/or Held
and/or
104 Address
Hold
CO
Date Point of
f ` Transportation Shipment
C by Common Destination
Carrier
Ei
El Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
i:iiPermit Issued to Registration Number
Name of Funeral Home Wilcox & Regan funeral home 01 821
Ha 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
C
t
11
` Permission is hereby granted to dispose of the human rem ' escribed ove a n icated.
Date Issued 0 9/0 5/201 2 Registrar of Vital Statistics OnL
cf,
(sig a re)
<; District Number 1 564 Place Town of Ticon eroga 10B3
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
l• Date of Disposition 1-"S.--I t Place of Disposition ?.../k. a,to,u—
(address)
lu
Ca
CC (section) �� (lot numb )
ii (grave number)
t Name of Sexton or Person in Cha e of Premises <<t .
(please print)
• SignatureA Title ag h )4t
(over)
DOH-1555 (02/2004)