Lambert, Tara NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Tara Ann Lambert Female
! Date of Death Age If Veteran of U.S. Armed Forces,
01 /28/2013 55 yrs. War or Dates No
Place of Death Town of Hospital, Institution or
City, Town or Village Ticonderoga Street Address Moses-Ludington Hospital
Manner of Death 0 Natural Cause D Accident 0 Homicide 0 Suicide riUndetermined 0 Pending
111
Circumstances Investigation
tu Medical Certifier Name Title
G Glen Chapman M.D.
Address
P.O. Box 29, Ticonderoga, New York 12883
Death Certificate Filed Town of District Number Register Number
City, Town or Village Ticonderoga 1 564
['Burial Date Cemetery or Crematory
01 /30/2013 Pine View Crematory
['Entombment Address
NE1Cremation Queensbury, New York •
Date Place Removed
2 Removal and/or Held
2❑and/or Address
t Hold
0CA
Date Point of
Transportation Shipment
0 by Common Destination
Carrier
El Disinterment Date Cemetery Address
El Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Wilcox & Regan funeral home 01 821
Address
ni 11 Algonkin St. , Ticonderoga, New York 12883
iiig Name of Funeral Firm Making Disposition or to Whom •
14 Remains are Shipped, If Other than Above
Address
Ia
>d' Permission is hereby granted to dispose of the human remains described above as indicated.
iM Date Issued 1 /3 0/2 01 3 Registrar of Vital Statistics ,G� '-1') , 1€----,,---
(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:
ILI Date of Disposition (-3)-(3 Place of Disposition u,tw r'v+-,
2 (address)
Ili
tfl
IC (section) / (lot number) (grave number)
ct Name of Sexton or Pers in Charge f Premises /�/l"'J 3eor
k.
( ease print)
IDS Title
>>: Signature
(over)
DOH-1555 (02/2004)