Hayes, Winona NEW YORK STATE DEPARTMENT OF HEALTH - t 53 ec
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Winona Mae Hayes Female
Date of Death Age If Veteran of U.S. Armed Forces,
09/08/2013 90 yrs. War or Dates No
I—: Place of Death Town of Hospital, Institution or
City, Town or Village Ticonderoga Street Address 4 Wayne Avenue
Manner of Death Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
U1 Circumstances Investigation
iii Medical Certifier Name Title
L Richard McKeever M.D.
Address
102 Race Track Road, Ticonderoga, New York 12883
iiigii Death Certificate Filed Town of • District Number Register Number
City, Town or Village Ticonderoga 1 564
❑Burial Date Cemetery or Crematory
❑Entombment 0 9/1 0/2 01 3 Pine View Crematory
Address
g.ii ®Cremation Queensbury, New York
Date Place Removed
Z Removal and/or Held
2❑and/or
Address�
Hold
C? Date Point of
Bi❑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 Funeral Home 01 821
Iii Address
iiiii 11 Algonkin St. , Ticonderoga, New York 12883
iiiii Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
I
111
Permission is hereby granted to dispose of the human rem i s escribed ve a dicated.
fli Date Issued 0 8/0 9/2 01 3 Registrar of Vital Statistics
(- • -tore) irrnP4:11"-L--
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:
til P , Disposition2/1/10.1 (,lty-e- o+rDate of Dis osition q-10. 3 Place of •..,
(address)
Ili
cn
cc (section) (lot number) (grave number)
tzt Name of Sexton or Pers in Charge of Premises Atper "a
int)
Signature Title ft--
(over)
DOH-1555 (02/2004)