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VanVleet, M. Avis Wilcox NEW YORK STATE DEPARTMENT OF HEAr_TH _ Vital Records Section Burial - Transit Permit Name First Middle Last Sex M. Avis Wilcox VanVleet Female Date of Death Age If Veteran of U.S. Armed Forces, 06/02/2012 81 years War or Dates t Place of Death Hospital, Institution or ii City, T wrMljlex Saratoga Springs Street Address Saratoga Hospital a Manner of Death©Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending III Circumstances Investigation lAi Medical Certifier Name Title Stephen Fishel M D. Address 100 Saratoga Village Bid Malta N Y Death Certificate Filed District Number Register Number City, T)C149QVOM Saratoga Springs 4501 254 ❑Burial Date Cemetery or Crematory ❑Entombment 06/05/2012 Pine View Crematory Address HE ]Cremation Queensbury N Y Date Place Removed Z ri❑Removal and/or Held and/or Address F- Hold f O Date Point of tL0 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 01821 Address 11 Algonkin St. , Ticonderoga NY 12883 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above • Address 1 ` Permission is hereby granted to dispose of the human remain ibe abolvs i dicated. Date Issued 06/04/2012 Registrar of Vital Statistics I • (signature) District Number 4501 Place Saratoga Springs I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: k a_::: ,�, ILI Date of Disposition (,f b I ll Place of Disposition I '�U IN) C l.t Or Iu1. (address) III Cr (section) (lot number) ( (grave number) C• Name of Sexton or Person in Char of Premises r, r ewu 1T * ► v (please print) III mi Signature ____ALTitle CI fPcL (over) DOH-1555 (02/2004)