Porter, Richard NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Per it
Name First Middle Last Sex
Richard W. Porter Male
:. Date of Death Age ' If Veteran of U.S. Armed Forces,
5/1 5/201 7 91 yrs. War or Dates 1 944-1 946
Place of Death Town of Hospital, Institution or Heritage Commons
City, Town or Village Ticonderoga Street Address Residential Health Care
0 Manner of Death 0 Natural Cause ❑Accident Homicide 0 Suicide Undetermined Pending
tki Circumstances Investigation
W Medical Certifier Name Title
0 Glen hapman M.D.
Address
102 Race Track Road, Ticonderoga, New York 12883
Death Certificate Filed t
Town of District Number Register Number yLI
`> City, Town or Village T i rondo raga 1 564
['Burial Date Cemetery or Crematory
❑Entombment 5/17/2017 Pine View Crematory
Address
fl remation Queensbury, New York
Date Place Removed
PP❑Removal and/or Held
.. and/or Address
H Hold
tali
0 Date Point of
c`0 Transportation Shipment
Q by Common Destination
ig Carrier
El Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Ni: Permit Issued to Registration Number
Name of Funeral Home Wilcox & Regan funeral home 01821
,:: Address
11 Algonkin St. , Ticonderoga, New York 12883
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
LEI
Permission is hereby granted to dispose of the human re ins des ' ed above as indicated.
Date Issued 5/1 7/201 7 Registrar of Vital Statistics c\
(signature
District Number 1564 Place Town of Ticonderoga
.:I cI certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
tit Date of Disposition 5/n i n Place of Disposition geV,.1-� C q Oro-,
(address)
111
CA
re (section) j(lot number) (grave number)
ci Name of Sexton or Person in Charge o4f Premises Lei r. p _)ami 1t
Z ®� (pldase print)
tit Signature G� Title iei� ..
(over)
DOH-1555 (02/2004)