Fish, Thomas ft pi
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Pe mit
`:' Name First Middle Last Sex
Thomas Harry Fish Male
Date of Death Age If Veteran of U.S.Armed Forces,
1 0/0 6/2 018 58 yr s. War or Dates No
j4 Place of Death Town of Hospital, Institution or
City, Town or Village Tit�onderogaitiii Street Address Moses-Ludington Hospital
Manner of Death Natural Cause El Accident Ei Homicide El Suicide 17 Undetermined ®Pending
t : Circumstances Investigation
g Medical Certifier Name Title
14 Eric Gorman M.D.
Address
CVPH, 75 Beekman Street, Plattsburgh, NY 12901
Death Certificate Filed Town of District Number Register Number
City, Town or Village Ticonderoga 1 564 37
❑Burial Date Cemetery or Crematory
DEntombment 10/1 0/201 8 Pi nP View Crematory
Address
; :]Cremation Queensbury, New York
Date Place Removed
Removal and/or Held
-0 and/or Address
Hold
Date Point of
Q Transportation Shipment
by Common Destination -
Carrier
Disinterment Date Cemetery Address
w LiQ 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
Name of Funeral Firm Making Disposition or to Whom
1- Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human rema" described a ve a "ndicated.
U. Date Issued 10/9/2018 Registrar of Vital Statistics \p -, \
iii
(signet
: District Number 1 564 Place Town of Ticonderoga
mi
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k:.>.
IU Date of Disposition /c!,)(lg Place of Disposition 411,s 440..
a (address)
al
ir (section) (Ipj number) c (grave number)
Name of Sexton or Person in Charge of Pre ises Lh7ri `.1*t
4 (pleas print)
Signature Title i T.1
(over)
DOH-1555 (02/2004)