Fleury Sr., Ernest NEW YORK STATE DEPARTMENT OF HEALTH ` ' W 1(13
Vital Records Section Burial - Transit Permit
4
Name First Middle Last Sex
Ernest Clarence Fleury, Sr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
. 06/05/2017 69 yrs. War or Dates Vietnam War
} Place of Death Town of Hospital, Institution or Ticonderoga EMA Club
City, Town or Village •TI conderoaa Street Address 9 Maple Wood Lane
3 Manner of Death®Natural Cause Li Accident Homicide 0 Suicide Undetermined Pending
Circumstances Investigation
w Medical Certifier Name Title
Q 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 1 8
❑Burial Date Cemetery or Crematory
❑Entombment 06/07/2017 Pine View Crematory
Address
Cremation Queensbury, New York
Date Place Removed
❑Removal and/or Held
and/or Address
E Hold
tip
C i Date Point of
C' Transportationfin El Shipment
5 by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Q 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 Whom
Remains are Shipped, If Other than Above
Address
it
Lti
9." Permission is hereby granted to dispose of the human remai - describ Bove as indicated.
Date Issued 06/0 6/201 7 Registrar of Vital Statistics ® mil\ ` 1 •
No (signature)
District Number 1 564 Place Town of Ticonderoga
1
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
l� Date of Disposition � ����� Place of Disposition ��,,lU}„✓
Cn+rnc7}o rs...,
', (address)
w
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C (section) /�l (lot number) (grave number)
it
ci Name of Sexton or Person in Charge of Premises f 'If�� �' �'""�
4 ( ease print)
Signature Title (ISEo 1..-
(over)
DOH-1555 (02/2004)