Wilcox, John NEW YORK STATE DEPARTMENT OF HEALTH 1A
Vital Records Section 4 • Burial - Transit Permit
Name First Middle Last Sex
John A. Wilcox Male
Date of Death Age If Veteran of U.S. Armed Forces,
November 15, 2011 88 War or Dates World War II
LZPlace of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
EtLI
i Manner of Death I X]Natural Cause I I Accident I I Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
0, Scott Biasetti Dr
Address
_,: 100 Park St.,Glens Falls,NY 12801
Death Certificate Filed 1 District Number Registeuk!b-r
i:,' City, Town or Village Glens Falls 5601 G/ re
❑Burial Date Cemetery or Crematory
November 17, 2011 Pine View Crematorium
❑Entombment Address
CI Cremation Quaker Road, Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
N
0 Date 1 Point of
aj I I Transportation ' Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date ! Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton-Healy Funeral Home 01596
Address
407 Bay Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
:t+ Remains are Shipped, If Other than Above
NAddress
its
` Permission is hereby granted to dispose of the human remains des i ed ab a n i ated.
Date Issued ///X./2 // Registrar of Vital Statistics
(signature)
District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
ui Date of Disposition gjo{/fl of Place of Disposition ,,�URN) C C+oN"-,
2 (address)
COILI
re
(section) 3 - (lot num r)' (grave number)
p Name of Sexton or Person in Charg of Premises t�51 ,� !�^
Z (please print)
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Signature A Title C'q ovn-Th(L (over)
DOH-1555(02/2004)