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Thompson, Ruth NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Vital Records Section Name First Middle Last Sex R.uth.........................:.......... ....Louise ..... .... ...... ......Tho_mpson... . .. ..... _ ...... ......... Female:.::::::::. Date of Death Age If Veteran of U.S.Armed Forces, J.anua.r 1.7. 1.9.9.5......€::8 ..::.. rs War or Dates No . :: ...... Y .. ,..... y _. :.Z Place of Death Hospital, Institution or W City Town or Village Street Address To....n _of. Tic.o.nde.roga.. f�as.es:...L.uding..t:a.n....�u.rs.i.ng..Home G. Manner of Death n Natural Cause Accident Homicide Suicide Undetermined Pending WI Circumstances Investigation .. .......... ........ _ .... ............. _:-: ......::. .... . .... .:_........ .. ., Medical Certifier Name Title © Se.an:...Maloney- ............ . . Address Tlconderoga .Health, Cente.r. Ticonderoga,. New..;York 12883 Death Certificate Filed District Number Register Number City,Town or Village Tnwn of Ti r-nnaPrnga 1 9,A4 .J Date Cemetery or Crematory ❑Burial Januar 20.....,.1995 .::::::.... ..., . P .ne View;_Cremator.y;;..;.....,;;..... . Y .. . , ®Cremation Address Ouesbur ., New York ............... .................... en Z Date Place Removed O;, ❑ Removal and/or Held 1-' and/or Hold ....... ........ _ ................. ...:_::: ........ . .....: .............. ..................:.. Address a Date Point of cn []Transportation by Shipment p' Common Carrier .......... ......: .....:. ............:::: . .-......... ........ ..... . Destination ............................. .. _ .... ....... ❑ Disinterment Date Cemetery Address . _: . . :..... .....:: _ ,...:. ...:._:::.. ❑ Reinterment Date CemeteryAddress Permit Issued to Registration Number Name of Funeral Firm. ...... W.a.1c.o.x-... ....Regan............._:: ......... ...... ..0.2.0.b,4...... Address 33....Alg.o.nl.�in....St. ,.....T.a..cond.era.g.a.,.....New....Y.ork........1.2:8.83 ::: . :. . .:::.::.... 7. Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above .: .::::.:.. ......-...:............ ...... --........ . ...... .. .::::--..... .... ......... . .. ..... _....... ..... ._ X; Address 17:I> ;a Permission is hereby granted to dispose of the human remains described above as in �ze' Date Issued 1/19/9 5 Registrar of Vital Statistics 7iV • (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: Z; Date of Disposition Place of Disposition /�/�/ /�� el�� Tipl (address) w Cn (section) (lot number) (grave number) cc pName of Sexton Person i Charge of Prem' es W (Please print) L� i�/ � �'� fY�; —77 Signature Title 1Q r DOH-1555 (10/89) p. 1 of 2 VS-61