Cossey, Robert Y 4qt�
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Robert Cossey Male
Date of Death Age If Veteran of U.S. Armed Forces,
iig 12/24/2017 91 yrs. War or Dates No
14 Place of Death Town of Hospital, Institution or
City, Town or Village Ticonderoga Street Address 42 Shhuyler Street
0 Manner of Death J Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined El Pending
1,I4 Circumstances Investigation
tu Medical Certifier Name Title '
ro k . , 0 k t-�r,b u.l+
Address
0 c 4 c -- K s t-t QC 1-e s Rd is NY /d'°O I
. Death Certificate Filed Town of District Number ) Register Number
City, Town or Village T iconde roger _ 1564
s>❑Burial Date Cemetery or Crematory
12/28/2017 Pine View Crematory
❑Entombment Address y
iffi®Cremation Queensbury_, New York
Date Place Removed
❑Removal and/or Held _
and/or Address
Hold
i
0 Date Point of
❑Transportation Shipment
3 by Common Destination
Carrier
❑Disinterment Date Cemetery Address
„j3 ❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Wilcox & Regan funeral home 01 821
iiil Address
11 Algonkin St. , Ticonderoga, NY 12883
" Name of Funeral Firm Making Disposition or to Whom
f. Remains are Shipped, If Other than Above
ff Address
ti:, Permission is hereby granted to dispose of the human remai described a ove 'ndicated.
Date Issued 1 2/2 7/2 01 7 Registrar of Vital Statistics (7-...,
] (sign r )
.ili ] District Number 1 564 Place Town of Ticondero a
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
Ili Date of Disposition/2/2 �-7 Place of Disposition ?,-►e�. ,, ) e-re- c„ "f
';; ! (addjess)
VI
M (section) (lot umber) (grave number)
0 Name of Sexton or P n . har of Premises );•-f ict-v1 69,z'vez` 4`�
(please print)
re Signature Title e,-e.r�-z, ---
(over)
DOH-1555 (02/2004)