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Hurlburt, Laura NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit 11,5 Name First Middle Last Sex Laura Mae tfurlburt Female Date of Death Age If Veteran of U.S. Armed Forces, 1 2/25/201 8 73 yrs. War or Dates No fr: Place of Death Town of Hospital, Institution or taZ City, Town or Village Ticonderoga Street Address 22 Pinnacle Street Manner of Death©Natural Cause 11 Accident El Homicide El Suicide 0 Undetermined El Pending Wig Circumstances Investigation Medical Certifier Name Title O 117anna $arras M T) Address 3767 Main Street, Warrensburg, New York 12885 Death Certificate Filed Town of District Number Register Number� )g City, Town or Village Ticonderoga 1 564 `� •['Burial Date Cemetery or Crematory ❑Entombment 1 2 /2 8/2 01 8 Pi nP View CrPmatnry Address ['Cremation Queensbury, New York Date Place Removed Removal and/or Held and/or Address LI Hold la C? Date Point of kTransportation Shipment 0 by Common Destination Carrier ">�pisinterment Date Cemetery Address ❑Reinterment Date Cemetery Address Permit Issued to Registration Number iiiii<= Name of Funeral Home Wilcox & Regan funeral home 01 821 Address ! 11 Algonkin St. , Ticonderoga, NY 12883 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above ' Address it Ui Permission is hereby granted to dispose of the human re ins descr-b bov s indicated. Date Issued 1 2/2 8/2 01 8 Registrar of Vital Statistic L." (signatur `` District Number/6Tc (I Place Town of Ticonderoga I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: 2 iii Date of Disposition0--3IH1' Place of Disposition P;,nU V'vya/ c Ky (address) w CC (section) -+� S (lot number) (grave number) ci Name of Sexton or Person in Charge of Premises V �� � (,G it�-f 2 (please print) : Signature � ` Title C.A.6,47(1.10 ' (over) DOH-1555 (02/2004)