Barber, Katherine NEW YORK STATE DEPARTMENT OF HEALTH t I C.
Vital Records Section 1 4 ..- 1. . Burial - Transit Permit
Name First Middle Last Sex
Katherine Barber Female
Date of Death Age If Veteran of U.S. Armed Forces,
Ei 01 /04/2013 98 yrs. War or Dates No
Place of Death Town of Hospital, Institution or
tuZ City, Town or Village Ticonderoga Street Address Moses-Ludington Hospital
a Manner of Death E Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
its Circumstances Investigation
LL Medical Certifier Name Title
Toni Sturm M.D.
Address
1019 Wicker Street, Ticonderoga, New York 12883
Death Certificate Filed Town of District Number Register Number
Mi City, Town or Village Ticonderoga 1 564 2
❑Burial Date Cemetery or Crematory
['Entombment01 /07/201 3 Pine View Crematory
Address
Cremation Oueensbury, New York
Date Place Removed
❑Removal and/or Held
and/or
Address
t
Hold
49 Date Point of
11 r—i
0 Li Transportation Shipment
el by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
glil Permit Issued to Registration Number
Name of Funeral Home Wilcox & Regan Funeral Home 01 821
Address
11 Algonkin St. , Ticonderoga, New York 12883
itil Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
ILI
P` Permission is hereby granted to dispose of the human rem ns described above as indicated.
Date Issued 1 /7//201 3 Registrar of Vital Statistics � �? acie_
(signature)
Ei District Number 1 564 Place Town of Ticonderoga
>.i II certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
jpj i4J�
Crw� r&p 1 ir '
t� -q Date of Disposition 11-IS Place of Disposition
(address)
Ui
CC (section) /+J (lot number) (grave number)
ti Name of Sexton or Person Charge of Premises l/hriJ + {
( ease print)
Signature L Title C?,whA-0111
(over)
DOH-1555 (02/2004)