Gregson, Eric NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Eric Gre son Male
Date of Death Age If Veteran of U.S.Armed Forces,
12/10/2019 69 Years War or Dates
Place of Death I Hospital,Institution or
Z City,Town or Village Ticonderoga Town Street Address Elizabethtown Community Hospital Moses Ludington
W Mannerof Death g
W ®Natural Cause Accident Homicide Suicide Undetermined El Pending
W Circumstances Investigation
U
W Medical Certifier Name Title
David Clauss MD
Address
1019 Wicker St,Ticonderoga Town,New York 12883
Death Certificate Filed District Number Register Number
City,Town or Village Ticonderoga 1564 80
Burial Date Cemetery,Crematory or Facility Name
12/12/2019 Pine View Crematory
Entombment Address
rVI
Cremation Queensbury Town,New York
Donation
0 ❑Removal Date Place Removed
and/or —7and/or Held
~ Hold Address
N
O
IL Date Point of
N Transportation Shipment
Q by Common
Carrier Destination
❑Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Edward L Kelly Funeral Home 00519
Address
PO Box 548,Schroon Lake,New York 12870
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped,If Other than Above
Address
Q
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/11/2019 Registrar of Vital Statistics 7onyaW g1io"son(Ekctromcat7ySW-ed)
(signature/
District Number 1564 Place Ticonderoga, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
H
Z Date of Disposition It lZ I Ij Place of Disposition /w�
W /address/
W
N (section) //at number/ (grave number)
Q
0 Name of Sexton or Person in Charge of Premiss
Z A—print)
Lu Signature Title ��'
DO H-1555(07/18)p 1 of 2
r
Public Health Law Sec. 4145(2b) 0 13 - 4 7 j
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home'named on burial permit
Official Funeral Directors Reg.or License#
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