Santos, Anton •
NEW YORK STATE DEPARTMENT OF HEALTH ` 41 147 b
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Anton Michael Santos Male
Date of Death Age If Veteran of U.S. Armed Forces,
07/24/2013 62 yrs. War or Dates Viet Nam
Place of Death Town of Hospital, Institution or
City, Town or Village Ticonderoga Street Address Moses-Ludington Hospital
ci Manner of Death m Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
fa Circumstances Investigation
U.
ill Medical Certifier Name Title
O Glen Chapman M.D.
Address
P.O. Box 29, Ticonderoga, New York 12883 •
Death Certificate Filed Town of District Number Register Number
City, Town or Village Ticonderoga 1 564
❑Burial Date Cemetery or Crematory
❑Entombment 2013 Pine View Crematory
Addressdress
®Cremation Queensbury, New York
Date Place Removed
Z ❑Removal and/or Held
2and/or Address
h=` Hold
CA
0 Date Point of
0 Li Transportation Shipment
Li by Common Destination
Carrier
Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
.„. Permit Issued to Registration Number
mi Name of Funeral Home Wilcox & Regan funeral home 01 821
Address .
iiEi 11 Algonkin St. , Ticonderoga, NY 12883
Name of Funeral Firm Making Disposition or to Whom
1 Remains are Shipped, If Other than Above
• Address
Ce
r' Permission is hereby granted to dispose of the human remains e cribed a o e as' icated.
Date Issued 0 7/2 6/2 01 3 Registrar of Vital Statistics
ture)
ft 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:
� O ) rron-cd r—
I�• Date of Disposition ']-�}-(3 Place of Disposition -Pi�tV� (� '�0
(address)
LEI
0
CC (section) it number) St (grave number)
0
Name of Sexton or Person in Charg of Premises
2 (plea print)
W 7
Signature Title CIL 1)lLOf,.
(over)
DOH-1555 (02/2004)