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Bisetti, Mary NEW YORK STATE DEPARTMENT OF HEALTH I 7f 51 Vital Records Section Burial - Transit Permit .i Name First Middle Last Sex Mary Antoinette Bisetti Female Date of Death Age If Veteran of U.S. Armed Forces, January 26, 2013 1 01 yrs. War or Dates No Place of Death Town of Hospital, Institution or Heritage Commons City, Town or Village Ticonderoga Street Address Residential Healthcare a Manner of Death© Natural Cause 0 Accident 0 Homicide Ei Suicide Undetermined 0 Pending 14t Circumstances Investigation w Medical Certifier Name Title C1 Glen Chapman M.D. Address P.O. Box 29, Ticonderoga, NY 12883 Death Certificate Filed Town of District Number Register Number 1 City, Town or Village Ticonderoga 1 564 ❑Burial Date Cemetery or Crematory QEntombment 1 /29/201 3 Pine View Crematory Address ®Cremation Queensbury, New York Date Place Removed Z ❑Removal and/or Held and/or Address 104. — Hold 10 Date Point of fi tit) Q Transportation Shipment a by Common Destination Carrier Q Disinterment Date Cemetery Address Q 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 Cr III Permission is hereby granted to dispose of the human re ains described above as indicated. Eil Date Issued 1 /2 8/201 3 Registrar of Vital Statistics —,- m (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 vs‘—‘3 Place of Disposition - „�U„> rc,.,t f:‘., 2 (address) LIE. U CC (section) ,(lot number (grave number) ti Name of Sexton or Person in Charge Premises drcpp I_(please prin 41 Signature Title C114 410-16, (over) DOH-1555 (02/2004)