Trepanier, Real , , .) 7y
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
RPa1 R. Prepanier Male
gi Date of Death Age If Veteran of U.S. Armed Forces,
kiii 07/26/201 7 85 yrs. War or Dates No
Place of Death Town of Hospital, Institution or
la_City, Town or Village Ticonderoga Street Address 1 26 Warner Hill Road
a Manner of Death to=Natural Cause 0 Accident EI Homicide 0 Suicide ElUndetermined El Pending
ill Circumstances Investigation
42
ui Medical Certifier ' Name Title
0. 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
07/28/2017 Pine View Crematory
El Entombment Address
ili®Cremation Queensbury, New York
Date Place Removed
Z Removal and/or Held
and/or Address
t Hold
44
0 Date Point of
Transportation Shipment
3 by Common Destination
in Carrier
Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
iN Permit Issued to Registration Number
iip Name of Funeral Home Wilcox & Regan Funeral Home 01 821
Address
Ei 11 Algonkin St. , Ticonderoga, New York 12883
iiil Name of Funeral Firm Making Disposition or to Whom
14 Remains are Shipped, If Other than Above
▪ Address
its
` Permission is hereby granted to dispose of the human re ' s describe abov- -s indicated.
iin Date Issued 7/28/201 7 Registrar of Vital Statistics \, CTY•N
( e ure)
<' District Number 1 564 Place Town of Ticonderoga
;M'I ceI certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
tLI▪ Date of Disposition 7 2_, i 7 Place of Disposition P,`i,. tom,. 1kv L✓ree-ein-dc-r
(address)
U
CA
CC (section) (lot number) (grave number)
▪ Name of Sexton or r .n harge of Premises �� 1' +" � ^"��'
Z (please print)
Signature Title t�re_r-, U/
mi
(over)
DOH-1555 (02/2004)