Smith, Anne NEW YORK STATE DEPARTMENT OF HEALTH # 5 ZZ,
Vital Records Section Burial - Transit Permit
L- f
Name First Middle Last Sex
Anne Celeste Smith Female
Date of Death Age If Veteran of U.S. Armed Forces,
October 2, 2012 46 yrs. War or Dates No
1- Place of Death Town of Hospital, Institution or
WCity, Town or Village Ticonderoga Street Address 1 71 -A The Portage
W Manner of Death 6 Natural Cause 0 Accident 0 Homicide Suicide Undetermined Pending
Circumstances Investigation
tu Medical Certifier Name Title
1:1 James Gabler RPA-C
Address
Ticonderoga Health Center, Ticonderoga, NY 12883
Death Certificate Filed Town of District Number Register Number
City, Town or Village Ticonderoga 1 564 6 0
❑Burial Date Cemetery or Crematory
['Entombment2012 Pine View Crematory
Address
®Cremation Queensbury, New York
Date Place Removed
9❑Removal and/or Held
and/or Address
t: Hold
lb
0 Date Point of
r Transportation Shipment
Ca by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment -
Date Cemetery Address
Permit Issued to Registration Number
<> Name of Funeral Home Wilcox & Regan funeral home 01 821
Address
11 Algonkin St. , P.O. Box 543, Ticonderoga, New York 12883
Name of Funeral Firm Making Disposition or to Whom
I Remains are Shipped, If Other than Above
Address
la
"` Permission is hereby granted to dispose of the human remain cribed abo e as i icated.
Date Issued 1 0/0 3/2 01 2 Registrar of Vital Statistics
(signs e)
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:
k /'''
ILIA Date of Disposition 1015111.. Place of Disposition essii,L�„t (, -c&fw/►,-
(address)
lAi
CO
CC (section) - (lot number) (grave number)
0 Name of Sexton or Person in Charge Premises Ai5
2 please print)
Signature jilTitle 0714 Ort
(over)
DOH-1555 (02/2004)