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Visconti, Josephine NEW YORK STATE DEPARTMENT OF HEALTH if (.1( Vital Records Section Burial - Transit Permit Name First Middle Last Sex Josephine C. Visconti Female Date of Death Age If Veteran of U.S. Armed Forces, September 8, 2012 92 yrs. War or Dates No Place of Death Town of Hospital, Institution or Moses-Ludington Adult City, Town or Village Ticonderoga Street Address Home, 1019 Wicker St. Manner of Death©Natural Cause ❑Accident ElHomicide ❑Suicide ❑Undetermined ❑Pending Circumstances Investigation tu Medical Certifier Name Title Toni M. Sturm M.D. Address 1019 Wicker Street, Ticonderoga, New York 12883 Death Certificate Filed Town of District Number Register Number City, Town or Village Ticonderoga 1 564 SZ ElBurial Date Cemetery or Crematory 09/10/2012 Pine View Crematory ❑Entombment Address • i®Cremation Queensbury, New York Date Place Removed Z Removal and/or Held '2 ❑and/or Address Hold Date Point of Q Transportation Shipment a 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 2 Address IL Permission is hereby granted to dispose of the human remains d ribed above s indi = d. Date Issued 9/1 0/2 01 2 Registrar of Vital Statistics (signatu 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: EE Date of Disposition 1•I1-I2_ Place of Disposition f;,4,hci) C, _ toriv�. (address) U >l (section) driji44- (lot nu ber) (grave number) fl Name of Sexton or Person in Charge of Premises S�h+�(' (please print) Signature L Title CYhi )L. (over) DOH-1555 (02/2004)