Crossman, Henry NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section - t Burial - Transit Pe it
Name First Middle Last Sex
Henry William Crossman Male
Date of Death Age If Veteran of U.S. Armed Forces,
05/20/2017 91 yrs. War or Dates 1 944-1 945
I- Place of Death Hospital, Institution or
Town of Herita a Commons
ZCity, Town or Village Ti r_endPmga Street Address Residential Health Care
0 Manner of Death 1 Natural Cause D Accident 0 Homicide 0 Suicide Undetermined 0 Pending
W Circumstances Investigation
uj• Medical Certifier Name Title
O Richard McKeever M.D.
Address
1019 Wicker Street mi cnndpr.oga NY 1
Death Certificate Filed Town of District Number Register Number
City, Town or Village Ticonderoga 1 564 1 5
•<! ❑Burial Date Cemetery or Crematory
❑Entombment 5/26/2017 Pine View Crematory
Address
®Cremation Queensbury, New York
Date Place Removed
❑Removal and/or Held
rr and/or Address
CZ Hold
o Date Point of
❑Transportation Shipment
C3 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 iiii Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
• Address
CC
Lu
CL
Permission is hereby granted to dispose of the human re ins descr'bedd above� as indicated.
Date Issued 5/2 3/201 7 Registrar of Vital Statistics i 1 i
(sign re)
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:
k
ILI Date of Disposition ( / Z 1 p Place of Disposition ;fu0 ,/ e, wr,nio.�
(address)
tii
le (section) /j(lot number) e- (grave number)
0 Name of Sexton or Person in Charge of Premises
G 4�.st .,- Ja^�►JI
2 /�' (prise print)
iu Signature (rl Title Y CiZe Mt01-
(over)
DOH-1555 (02/2004)