Chappell, Pauline NEW YORK STATE DEPARTMENT OF HEALTH t ,')
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Pauline C. Chappell Female
Date of Death Age If Veteran of U.S. Armed Forces,
10/22/2013 79 yrs. War or Dates No
Place of Death Town of Hospital, Institution or
Z City, Town or Village Ticonderoga Street Address 393 Baldwin Road
ili
• Manner of Death 0 Natural Cause ❑Accident El Homicide El Suicide ❑Undetermined ❑Pending
Ut Circumstances Investigation
01
Lu Medical Certifier Name Title
Q Max Crossman M_D_
Address
65 Poultney Street Whitehall, NY 12887
Death Certificate Filed Town of __,,__Whitehall,
strict Number Register Number
City, Town or Village Ticonderoga 1 564 73
❑Burial Date Cemetery or Crematory
A d
['Entombment 1dre 023/201 3 Pine View Crematory
ss
cremation Queensbury, New York
Date Place Removed
Z ❑Removal and/or Held
and/or Hold Address
F_-
41
O Date Point of
CL
❑Transportation Shipment
a by Common Destination
Carrier
❑Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
• Permit Issued to Registration Number
Name of Funeral Home Wilcox & Regan Funeral Home 01 821
inii Address
11 Algonkin St. , Ticonderoga, NY 12883
IEil Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
• Address
IX.
to
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Permission is hereby granted to dispose of the human re ' s describe bove = - indicated.
Iii Date Issued 1 0 2 3/2 01 3 Registrar of Vital Statistics ,
/ (sig t e) 4°I(I\91)-eIr\
District Number 1 564 Place Town of Ticonde oga
• I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ill Date of Disposition t0//ri 3 Place of Disposition go tN„i (11-4,476%-
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(address)
W
til
CC (section) h/
fit number) (grave number)
Name of Sexton or Person ' Charge of Premises n• f
z (pleas print)
7Riii Signature Title CTiil Ili)(
(over)
DOH-1555 (02/2004)