Pooler, Carl 4 4 3 ZZ
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Carl Winslow PoolPr Male
Date of Death Age If Veteran of U.S. Armed Forces,
0 4/21 /2 01 6 88 yrs. War or Dates No
• Place of Death Town of Hospital, Institution or
ii City, Town or Village Ti conder(1(_.-a Street Address Moses-Ludington Hospital
O Manner of Death®Natural Cause LAccident 0 Homicide 0 Suicide 0 Undetermined n Pending
W Circumstances Investigation
tu Medical Certifier Name Title
II Todd R. Waldorf D_0_
Address
1 01 9 Wicker Street, Ticonderoga, NY 12883
Death Certificate Filed Town of District Number Register Number
City, Town or Village Ticonderoga 1564 20
«< ❑Burial Date Cemetery or Crematory
4/26/2016 Pine View Crematory
b. ❑Entombment Address
®Cremation Queensbury, New York
Date Place Removed
Z El Removal and/or Held
2 and/or
Address
ff
Hold
C? Date Point of
CL
❑Transportation Shipment
G by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Mi Permit Issued to Registration Number
Name of Funeral Home Wilcox & Regan funeral home 01 821
Address
11 Algonkin St. , Ticonderoga, NY 12883
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
;; Address
it
ti
CL
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 4/2 4/2 01 6 Registrar of Vital Statistics d �r�
(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:
Z
Ill Date of Disposition tiftlfi( Place of Disposition s „..., ( 46-1.-.
2 (address)
LEE
CO
CC (section) ,(lot number) (grave number)
▪ Name of Sexton or Person in Char a of Premises rn �,.-..St
2r (pease pant)
ILI Signature (2 Title ��'�
(over)
DOH-1555 (02/2004)