Martin, Helen NEW YORK STATE DEPARTMENT OF HEALTH 4 1
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Helen Lucille Martin Female
Date of Death Age If Veteran of U.S. Armed Forces,
iig 01 /02/2013 85 yrs. War or Dates No
14 Place of Death Town of Hospital, Institution or
ZCity, Town or Village Ticonderoga Street Address 98 Grace Avenue
0 Manner of Death r Natural Cause 0 Accident 0 Homicide ❑Suicide Undetermined Pending
tit Circumstances Investigation
In Medical Certifier Name Title
Q Glen Chapman M.D.
Address
P.O. Box 29, Ticonderoga, New York 12883 •
li Death Certificate Filed Town of District Number Register Number
City, Town or Village Ticonderoga 1 564 01
Burial Date Cemetery or Crematory
[]Entombment 01 /04/201 3 Pine View Crematory
Address
``®Cremation Queensbury, New York
Date Place Removed
Z Removal and/or Held
C �▪ and/or
Address
h• Hold
U
0 Date Point of
f1ii:0 Transportation Shipment
ES by Common Destination
iii Carrier
❑Disinterment Date Cemetery Address
. Q 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
I
f •
P" Permission is hereby granted to dispose of the human re ains described above as indicated.
Date Issued 01 /0 4/201 3 Registrar of Vital Statistics " G1
(signature)
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:
Ill p [ S DispositionP,PJfL 1d li.c�' !/ "DDate of Dis osition •— —/3 Place of
2 (address)
la
U)
CC (section) (lot number) (grave number)
ci Name of Sexton or erson ' Ch Premises60-_-_vii_
/4
(please print)
Signature A 4 Title 3?te,A ure- /45�
(over)
DOH-1555 (02/2004)