Morin, Dean 4 2 - a 14 2°it
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Dean T. Morin Male
Date of Death Age If Veteran of U.S. Armed Forces,
03/09/2017 66 years War or Dates No
F- Place of Death Town of Hospital, Institution or
6 City, Town or Village Ticonderoga Street Address 59 Adirondack Drive
O Manner of Death 0 Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
W Circumstances Investigation
ILI Medical Certifier Name Title
a C. Francis Varga M.D.
Address
P.O. Box 768, Lake Placid, New York 12946
Death Certificate Filed Tow of District Number Register Number
City, Town or Village Ticonderoga 1 564
❑Burial Date Cemetery or Crematory
03/13/2017 Pine View Crematory
❑Entombment Address
®Cremation Queensbury, New York
Date Place Removed
Z ri❑Removal and/or Held
and/or
� Address i
to
Hold
O Date Point of
i2 Transportationtn, Shipment
ci by Common Destination
ei Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
iiia Permit Issued to Registration Number
Name of Funeral Home Wilcox & Regan funeral home 01 821
Address
11 Algonkin St. , Ticonderoga, New York 12883
Vilil Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
C
la
Permission is hereby granted to dispose of the human re ai s describ abo e as indicated.
Date Issued 3/1 2/201 7 Registrar of Vital Statistics ,-,/ -
signature)
Eiiii District Number 1 564 Place Town of Tic deroqa
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
jj
til Date of Disposition 3l/y/7 Place of Disposition2)1auIa4 ) l, -e.44/ .7 ,/�
2 / (address)/Ili
Ili (section) pot number) (grave number)
1
Name of Sexton P on i Charge of Premises A . 1 , ,v1 4-- G-e-i �.
2 (please print)
Signature Title f(2-)444:.-- 3, -
(over)
DOH-1555 (02/2004)