Sorenson, Ronald 11 7g.ie
NEW YORK STATE DEPARTMENT OF HEATH' 1
Vital Records Section Burial - Transit Permit
<: Name First Middle Last Sex
Ronald Michael corengnn Male
Date of Death Age If Veteran of U.S. Armed Forces,
October 1 1 , 201 7 76 yrs. War or Dates Vietnam War
f Place of Death Town of Hospital, Institution or
City, Town or Village Ticonderoga Street Address 1 007 Wicker Street
IL'0 Manner of Death®Natural Cause C Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
lii Circumstances Investigation
la Medical Certifier Name Title
Herbert Ravel M_D_
Address
P.O. Box 67, Elizabethtown, New York 12932
Death Certificate Filed Town of District Number Register Number
City, Town or Village Ti concdPrnga 1 564 38
'':❑Burial Date Cemetery or Crematory
❑Entombment 10/13/2017 Pine View Crematory
Address
:: ®Cremation Queensbury, New York
Date Place Removed
❑Removal and/or Held
and/or Address
fft Hold
Date Point of
❑Transportation Shipment
E by Common Destination -
Carrier
❑Disinterment Date Cemetery Address
El 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 WIUhom
Remains are Shipped, If Other than Above
IAddress
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 10/1 3/2 01 7 Registrar of Vital Statistics I • Sc.','
(signatu )
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:
Date of Disposition I'/jb in Place of Disposition ry,J• C' 6
(address)
40
ir (section) ((lot number) (grave number)
aName of Sexton or Person in Charge of Prem- es sv S it.t4 '
(p ease print)
Signature t^^ v'' Title ( ,(-
(over)
DOH-1555 (02/2004)