Letson, Doris NEW YORK STATE DEPARTMENT OF HEALTH '
Vital Records Section Burial - Transit Permit
Name First • Middle Last Sex
Doris M. Letson Female
Date of Death Age If Veteran of U.S. Armed Forces,
1 0/1 0/201 3 90 yrs. War or Dates No
Place of Death Town of Hospital, Institution or
Z City, Town or Village Ticonderoga Street Address 1 42 Cannonball Path
0 Manner of Death 0 Natural Cause ❑Accident ❑Homicide ElSuicide riUndetermined Ei Pending
Circumstances Investigation
W Medical Certifier Name Title
0 Glen Chapman M.D.
Address
P.O. Box 29, Ticonderoga, NY 12883
Death Certificate Filed Town of District Number Register Number
City, Town or Village Ticonderoga 1 564
❑Burial Date Cemetery or Crematory
❑Entombment 1 0/1 1 /201 3 Pine View Crematory
Address
®Cremation uensbnr _New YoQQate
Place Removed
❑
Removal and/or Held
it.: andHold/or Address
ta
0 Date Point of
Transportation Shipment
0 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
Address
CC
ft
Permission is hereby granted to dispose of the human rem ' described a o e as i i ted.
Date Issued 1 0/1 1 /2 01 3 Registrar of Vital Statistics _ i
(sign tur
District Number 1 564 Place Town of Ticon eroga
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k L Date of Disposition to 1 i5(p Place of Disposition �`'�I'
li4J C dr r`
(address)
111
CC (section) (1 number) (grave number)
ta Name of Sexton or Person i Charge Premises i �>4 _cNq
(please rint)
ILI
Signature Title Gr1 r►101.,
(over)
DOH-1555 (02/2004)