Wallace Jr., William f 3 11 35 b
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
William Dean Wallace, Jr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
07/10/2013 70 yrs. War or Dates No
1 Place of Death Town of Hospital, Institution or
ifi City, Town or Village Ticonderoga Street Address Heart Bay of Lake George
Manner of Death X❑Natural Cause ❑Accident ❑Homicide ❑Suicide 0 Undetermined ❑Pending
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Circumstances Investigation
iti fl Medical Certifier Name Title
C. Francis Varga M.D.
Address
P.O. Box 768, Lake Placid, New York 12946
Death Certificate Filed Town of District Number Register Number
City, Town or Village Ticonderoga 1 564
❑Burial I Date Cemetery or Crematory
❑Entombment 2013 Pine View Crematory
Addressddress
, Cremation Queensbury, New York
Date Place Removed
Z 1-1❑Removal and/or Held
and/or Address
I= Hold
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0 Date Point of
Transportation Shipment
0 by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
iiiii: Permit Issued to Registration Number
Name of Funeral Home Wilcox & Regan Funeral Home 01 821
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Address
iin 11 Algonkin St. , Ticonderoga, New York 12883
ER Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
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` Permission is hereby granted to dispose of the human re ains described above as indicated.
Date Issued 0 7/1 2/201 3 Registrar of Vital Statistics ,,,,,c/ 7Y)- A l€L-._
(signature)
Ei 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:
III Date of Disposition 1-(1-1, Place of Disposition ,,,,taA/ C ���
(address)
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CC (section) (lot umber) < (grave number)
Name of Sexton or Pers in Charge f Premises iird J/
Z (please pr t)
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gg Si nature ` Title G17w
(over)
DOH-1555 (02/2004)
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