Samonek, Evelyn NEW YORK STATE DEPARTMENT OF HEALTH a t IN
Vita! Records Section • Burial - Transit Permit
Name First Middle Last Sex
Evelyn Grace Samonek Female
Date of Death Age If Veteran of U.S. Armed Forces,
8/07/2012 85 yrs. WarorDates No
}- Place of Death Town of Hospital, Institution or
ZCity, Town or Village Ticonderoga Street Address 8 Fort Ti Road
ci Manner of Death 0 Natural Cause El Accident El Homicide 0 Suicide 0Undetermined n Pending
11.1 Circumstances Investigation
tu Medical Certifier Name Title
Glen Chapman M.D.
Address
P.O. Box 29, Ticonderoga, New York 12883
Death Certificate Filed Town of District Number Register NIu�ber
City, Town or Village Ticonderoga 1 564 4
❑Burial Date Cemetery or Crematory
El Entombment 8/09/2012 Pine View Crematory
Address
Cremation Queensbury, New York .
Date Place Removed
2. FiRemoval and/or Held
and/or Address
f= Hold
CO
0 Date Point of
EZ. Transportation Elp Shipment
C3 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 01821
Address
ft 11 Algonkin St. , P.O. Box 543, Ticonderoga, NY 12883
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
;, Address
IA
,ti, Permission is hereby granted to dispose of the human rem ins described above as indicated.
Date Issued 8/09/2012 Registrar of Vital Statistics , a..1 - ..
Rii
(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:
1U Date of Disposition q-10-I'1 Place of Disposition fint(1 61-4rim-,
tit
(address)
0
I (section) (lot number) (grave number)
0 /
1 Name of Sexton or Pers n in Charge of Premises h r,�'c . ,st,,,.,,4-
(ple se print)
Signature ( L, Title Ctlt M (t-
(over)
DOH-1555 (02/2004)