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Fleming, Helen NEW YORK STATE DEPARTMENT OF HEALTH 1 4 4 71 Vital Records Section Burial - Transit Permit Name First Middle Last Sex Helen T. Fleming Female fii Date of Death Age If Veteran of U.S. Armed Forces, 0 2/1 1 /2 01 3 101 yr s. War or Dates No E44 Place of Death Town of Hospital, Institution or • ZCity, Town or Village Ticonderoga Street Address 27 Lead Hill Road ct Manner of Death KA Natural Cause ElAccident El Homicide 0 Suicide riUndetermined ri Pending Circumstances Investigation tu Medical Certifier Name Title Q Glen Chapman M.D. Address P.O. Box 29, Ticonderoga, NY 12883 Death Certificate Filed Town of District Number Register Number Ei City, Town or Village Ticonderoga 1 564 /A iig El Burial Date Cemetery or Crematory ❑Entombment 02/13/2013 Pine View Crematory Address iiiii ©Cremation Queensbury, New York Date Place Removed Z El Removal and/or Held and/or i; Hold Address i O Date Point of Transportation Shipment el by Common Destination Carrier ❑Disinterment Date Cemetery Address iN ElReinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Wilcox & Regan funeral home 01 821 Mi Address 11 Algonkin St. , P.O. Box 543, Ticonderoga, NY 12883 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above • Address f CL Permission is hereby granted to dispose of the human rem ins described above as indicated. iii Date Issued 2/1 3/2 01 3 Registrar of Vital Statistics -y71 . ester`-, t (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: III 'i • Date of Disposition Z-ly-t3 .Place of Disposition „aVli�! Cwwcbcic,_ (address) LEI (section) h r� .(lot number) (grave number) Name of Sexton or Pers n in Charge of Premises rl ,Q n ..ice 1(p/ease print) Signature Title at-WOOL (over) DOH-1555 (02/2004)