Fiorello, Ruth ii via
NEW YORK STATE DEPARTMENT OF HEALTH.'
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Ruth M. Fiorello Female
•
Date of Death Age If Veteran of U.S. Armed Forces,
10/25/2013 95 yrs. War or Dates W.W.II
. Place of Death Town of Hospital, Institution or Heritage Commons
Z City, Town or Village Ticonderoga Street Address Residential Healthcare
Ill
a Manner of Death 1171 Natural Cause Accident Homicide Suicide Undetermined Pending
LU Circumstances Investigation
u Medical Certifier Name Title
a 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 75
0 Burial Date Cemetery or Crematory
10/28/2013 Pine View Crematory
. 0Entombment Address
'::Cremation Queensbury, New York
Date Place Removed
Z❑Removal and/or Held
9 and/or Address
f= Hold
CA
0 Date Point of
oiQ Transportation Shipment
G 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
11 Algonkin St. , Ticonderoga, New York 12883
Name of Funeral Firm Making Disposition or to Whom
• Remains are Shipped, If Other than Above
• Address
tr.
LL[
CL
Permission is hereby granted to dispose of the human remai escribed ove s indicated.
Date Issued 1 0/2 8/201 3 Registrar of Vital Statistics ` �,r UY�
(sign .-
e)
IT 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:
fr
ill Date of Disposition johcfli , Place of Disposition ,,tail `,�,, o{
(address)
11
CC
IX (section) (lot number) ' (grave number)
Name of Sexton or Person incharge of Pr mises h,`cQt► S inwir
(please print)
�•
• Signature i— Title
9 � catiopW,
(over)
DOH-1555 (02/2004)