Brown, William # I /Oa
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
William Thomas Brown Male
Date of Death Age If Veteran of U.S. Armed Forces,
December 14, 2018 37 years War or Dates 2000 - 2004
j Place of Death Town of Hospital, Institution or
City, Town or Village Ticonderoga Street Address 9 Loneraan Lane
Manner of Death 0 Natural Cause 0 Accident f5 j Homicide EiSuicide riUndetermined EIPending
I Circumstances Investigation
Medical Certifier Name Title
Michael Siki ri cr,
Address
50 Broad Street, Waterford, NY 12188
Death Certificate Filed Town of District Number Register Number
gii City, Town or Village Ticonderoga 1 5 6 4 4 7
` .❑Burial Date Cemetery or Crematory
`< ❑Entombment 2/24/2018 Pine View Crematory
Address
`.®Cremation Queensbury, New York
Date Place Removed
❑Removal and/or Held
and/or Address
tit Hold
V
Date Point of
piQ Transportation Shipment
3 by Common Destination -
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Wilcox & Regan funeral home 01 821
Address
Iiiiiiiii 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 . sc,kibed abo s indicated.
12/17/2018 / `�
>� Date Issued Registrar of Vital Statistics �/ " �q,�
r / (sign re
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:
t',
Ili Date of Disposition 11 !2`1 Id Place of Disposition t�...1��.+ j s��
a (address)
E
to
(section) p�number) (grave number)
iii
fl Name of Sexton or Person in Charge of Premises 11�f s
t^�`
2 (plea print)
41 Signature (.4 „it,-
Title iirf►n►4JDf--
(over)
DOH-1555 (02/2004)