Law, Nancy NEW YORK STATE DEPARTMENT OF HEALTH il 363
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Nancy Jean Law Female
Date of Death Age If Veteran of U.S. Armed Forces,
June 23, 201 3 70 yrs. War or Dates No
Place of Death Town of Hospital, Institution or
;Z City, Town or Village Ticonderoga Street Address 1 4 Cottage Road
Manner of Death a Natural Cause ❑Accident ❑Homicide ❑Suicide ri❑Undetermined El Pending
11,1 Circumstances Investigation
tu Medical Certifier Name Title
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 y/
> i>['Burial Date Cemetery or Crematory
6/25/2013 Pine View Crematory
.:A❑Entombment Address
®Cremation Queensbury, New York
Date Place Removed
Z. ❑Removal and/or Held
91 and/or Address
Cl)
Hold
0 Date Point of
ti❑Transportation Shipment
0 by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
li 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
ill
CL
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 6/2 5/201 3 Registrar of Vital Statistics yU�t, -� . C� '
`` (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:
Z
111 Date of Disposition 4~Z6-0 Place of Disposition X,14L 1. < tctvs—
(address)
Ill
CC (section) (lot number) (grave number)
4
ci• Name of Sexton or Person in Charge of P emises C `�
(pi ase print)
• Signature Title afmA101
(over)
DOH-1555 (02/2004)