Wilbur, Jack NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section - 111
Burial - Transit Permit
Name First Middle Last Sex
,Tack R, Wilbur Male
Date of Death Age If Veteran of U.S. Armed Forces,
2/27/2011 77 yrs. War or Dates 1949 - 1954
l Place of Death Hospital, Institution or
City, Town or Village Town of TiconderogAtreet Address Moses-Ludington Hospital
ILL0 Manner of Death®Natural Cause ElAccident ElHomicide ElSuicide ❑Undetermined ❑Pending
ILI Circumstances Investigation
tu Medical Certifier Name Title
Glen Chapman M.D.
Address
Wicker Street, Ticonderoga, New York 12883
Death Certificate Filed District Number Register Number
City, Town or Village Town of Ticonderoga 1 564 10
>';;:DBurial Date Cemetery or Crematory
❑Entombment 3/01 /201 1 Pine View Crematorium
Address
Cremation Queensbury, New York
Date Place Removed
g❑Removal and/or Held
and/or
Address h;;;
Hold •
CA
0 Date Point of
cL❑Transportation Shipment
Et by Common Destination
Carrier
❑Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
Permit Issued to .Registration Number
Name of Funeral Home Mason Funeral Home 01136
Address
18 George Street, Ft. Ann, New York 12827
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
#C
ilif
Permission is hereby granted to dispose of the human re ains descr'bed a• •ve as indicated.
'< Date Issued2/28/2 01 1 Registrar of Vital Statistics y 0V\--
,(signature) `
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:
k
1U Date of Disposition 3-3- ( ( Place of Disposition P'n e v,.e ) C e.,, aj it I'j WI
(address)
11ltil
aCC (section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises 1 h rn oT�r ery i,e`k
�--- _ (please print)
4
Signature -c rw Title CC tv)a ory l4-SS'
(over)
DOH-1555 (02/2004)