Millington Sr., John NEW YORK STATE DEPARTMENT OF HEALTH ,: --
Vital Records Section Burial - Transit Permit
Name First Middle Last ' Sex
__ John E.Millington Sr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
06/26/2018 77 Years War or Dates
Place of Death Hospital, Institution or
City, Town or Village Ticonderoga Town Street Address Heritage Commons Residential Health Care
ri Manner of Death 0 Natural Cause 0 Accident El Homicide 0 Suicide El Undetermined El Pending
iiii
Circumstances Investigation
Medical Certifier Name Title
Richard Mckeever MD
Address
1019 Wicker St,Ticonderoga Town,New York 12883
r
Death Certificate Filed District Number Register Number
City, Town or Village Ticonderoga 1564 25
❑Burial Date Cemetery or Crematory
Lif 06/27/2018 Pine View Crematory
❑Entombment
Address
®Cremation Queensbury, New York
Date Place Removed
Removal and/or Held
and/or Address
=- Hold
Date Point of
Q Transportation Shipment
by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Wilcox&Regan 01821
,y�
E Address
11 Algonkin St,Ticonderoga,New York 12883
Name of Funeral Firm Making Disposition or to Whom
`I Remains are Shipped, If Other than Above
Address
- Permission is hereby granted to dispose of the human remains described above as indicated.
zDate Issued 06/27/2018 Registrar of Vital Statistics Tonya M''Thompson(ECectronicallySigned)
�. (signature)
F ,
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:
Date of Disposition 4(z (If Place of Disposition S.J.„ (0-0, 0—..
(ad ress)
(section) lot number) f, (grave number)
4 trii
s Name of Sexton or Person in Charge of Premises (pie print) ,„
Signature 1.4 Title C ut futt_
(over)
DOH-1555 (02/2004)