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Gibbs, Sherry NEW YORK STATE DEPARTMENT OF HEALTH', . l Vital Records Section Burial - Transit Permit Name First Middle Last Sex Sherry Arlene Gibbs Female Date of Death Age If Veteran of U.S. Armed Forces, 02/06/2018 79 yrs. War or Dates No Place of Death Town of Hospital, Institution or City, Town or Village Hague Street Address 239 Decker Hill Road Manner of Death©Natural Cause El Accident 0 Homicide 0 Suicide Undetermined Pending 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 Number 1 >> City, Town or Village Haque 5653 ❑ Date Burial Cemetery or Crematory []Entombment 2/8/2018 Pine View Crematory �>` Address j EgCremation Haque, New York 12836 Date Place Removed ❑Removal and/or Held . and/or r ; Address Hold ?41) Date Point of �' Trans ortation ❑ p Shipment i by Common Destination Carrier ni Q 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 f- Remains are Shipped, If Other than Above Address LEA Permission is hereby granted to dispose of the human remains described abov as indicated. Date Issued 2/8/2 01 8 Registrar of Vital Statistics M (signature) District Number 5 6 53 Place Tow a e. I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z. W. Date of Disposition 21 Old Place of Disposition i�a,.li... ��-c.tvr�-., ' (address) L C CC (section) n..(lot number (grave number) Name of Sexton or Person in Charge of P mises , ti,,itt L ( lease pant) Signature Title /13fhht(�11�- (over) DOH-1555 (02/2004)