Sanders Sr., Willard 4 ', #ll1
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Willard Arthur Sanders, Sr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
02/03/2016 78 yrs. War or Dates No
1—. Place of Death Town of Hospital, Institution or
•
LaCity, Town or Village Ticonderoga Street Address 39 Wayne Avenue
o Manner of Death 0 Natural Cause 0 Accident n Homicide D Suicide Undetermined Pending
W. Circumstances Investigation
W Medical Certifier Name Title
0 C. Francis Varga M_D.
Address
P.O. Box 768, Lake Placid, NY 12946
Death Certificate Filed Town of District Number Register Number
City, Town or Village Ticonc3Prnga 1 564 6
❑Burial Date Cemetery or Crematory
QEntombment 02/08/2016 Pine View Crematory
Address
aCremation Queensbury, New York
Date Place Removed
g �Removal and/or Held
and/or Address
= Hold
fel
0 Date Point of
Transportation Shipment
0 by Common Destination
Carrier
Q Disinterment Date Cemetery Address
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
2 Address
1r
t:U
Permission is hereby granted to dispose of the human re ains described above as indicated.
Date Issued 0 2/0 5/201 6 Registrar of Vital Statistics ,(.44.,nJ )11 • LZGCc—r--.
(signature)
iM 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:
luI Date of Disposition . -,9/l e Place of Disposition l ihe' V.Z A/ c.fe,n4(4cc Y
2 (address)
Ui
cc (section) (lot number) (grave number)
0
0 Name of Sexton or Person in Charge of Premises Tel pi y Ste,Cc.S
z (please print)
Signaturefr Title Gfte9 F
(over)
DOH-1555 (02/2004)