Walker, Dorothy NEW YORK STATE DEPARTMENT OF HEALTH ., # 5o A
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Dorothy W. Walker Female
6. Date of Death Age If Veteran of U.S. Armed Forces,
09/26/2012 96 yrs. War or Dates No
-.. Place of Death Town of Hospital, Institution or
W City, Town or Village Ticonderoga Street Address 419 Black Point Road _
0 Manner of Death Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
WW Circumstances Investigation
Medical Certifier Name Title
0 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 ,5'9
El Burial Date Cemetery or Crematory •
❑Entombment 09/28/2012 Pine View Crematory
Address
®Cremation Queensbur , New York
Date Place Removed
Z❑Removal and/or Held
2 and/or Address
Hold
CO
0 Date Point of
n"El Transportation Shipment
G by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Nii 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
t
tLI
91: Permission is hereby granted to dispose of the human remains cribed ab ve a ' dicated.
Date Issued 9/2 8/201 2 Registrar of Vital Statistics ;n
0 lure)
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:
t
lif Date of Disposition to(l (1t Place of Disposition Pp.,Ui , -
(address)
Ill
CC (section) i - (lot number) (grave number)
'} Name of Sexton or Perso in Charge of P mises <<i ;441
please print)
Signature L. Title [i2 n1
(over)
DOH-1555 (02/2004)