Granger, Sandra f ffRZo
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
:.::,:i Name First Middle Last Sex
Sandra A.M. Granger Female
Date of Death Age If Veteran of U.S. Armed Forces,
1 1 /1 3/201 8 75 yrs. War or Dates No
}-- Place of Death Town of Hospital, Institution or
City, Town or Village Putnam Station Street Address 1 7242 State Rte. 22
o Manner of Death 0 Natural Cause ❑Accident ❑Homicide ❑Suicide ❑ Undetermined ❑Pending
i Circumstances Investigation
ILI Medical Certifier Name Title
0 Glen Chapman M.D.
Address
P.O. Box 29 , Ticonderoga, NY 12883
Death Certificate Filed Town of District Number Register Number
City, Town or Village Putnam Station 5763
0 Burial Date Cemetery or Crematory
11 /15/2018 Pine View Crematory
;;❑Entombment Address
®Cremation Queensbury, New York
Date Place Removed
g. Removal and/or Held
{-❑and/or Address
M= Hold
11)
d Date Point of
❑Transportation Shipment
0 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. , Ticonderoga, New York 12883
qy Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
CC
Ili
CL
Permission is hereby granted to dispose of the human r described above as indicated.
\
Date Issued 1 1 /1 5/2 01 8 Registrar of Vital Statistics NaiLe -*elm
(signat re)
District Number 5763 Place Town of Putnam Station
IF- I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
//rr
i Date of Disposition IIIiT ilg Place of Disposition f...�� 4s-elvrq.....
2 (address)
Ui
til
CC (section) t(lot number) (grave number)
. Name of Sexton or Person in Charge of Premises (<,hp11 6,ait
Z ! (please print)
iLi . 4--
Signature �( / Title NE'N1112
(over)
DOH-1555 (02/2004)