Allen, Geraldine NEW YORK STATE DEPARTMENT OF HEALT I... ' -. r' 3 t1
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Geral1ine F_ Allen Female
Date of Death Age If Veteran of U.S. Armed Forces,
07/06/2013 94 yrs. War or Dates No
I•- Place of Death Town of Hospital, Institution or Heritage Commons
X City, Town or Village Ticonderoga Street Address
IliRPGiclPnfiial HPalthcarP
Manner of Death 0 Natural Cause Accident Homicide Suicide Undetermined Pending
tit0Circumstances Investigation
ul Medical Certifier Name Title
14 Richard McKeever M.D.
Address
1019 Wicker Street, Ticonderoga, NY 12883
11. Death Certificate Filed Town of District Number Register Number
City, Town or Village Ticondernga 1 564 43
0 Burial Date Cemetery or Crematory
DEntombment 07/11/2013 Pine View Crematory
Address
®Cremation Queensbury, New York
Date Place Removed
•❑Removal and/or Held
0. and/or Address
F= Hold
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Date Point of
n`' Transportation❑ P Shipment
0 by Common Destination
Carrier
0 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 •
,a Address
Cr
LU
'' Permission is hereby granted to dispose of the human rem ins described above as indicated.
Sii Date Issued 07/0 9/201 3 Registrar of Vital Statistics i yY) • aee.-yA---
(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:
ifs! Date of Disposition )1 It l 13 Place of Disposition est (t jo ._
2 (address)
Ili
tfl
CC (section) _ (lot number)) (grave number)
Ci Nzame of Sexton or Per n in Charge Premises L 3�"`"
(please print)
Signature Title _ k
(over)
DOH-1555 (02/2004)