Mattison, Dean NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
iiiiiiiii Name First Middle Last Sex
Dean Kenneth Mattison Ma1P
Date of Death Age If Veteran of U.S. Armed Forces,
October 17, 2016 65 yrs. War or.Dates No
j-:- Place of Death -City, ..Hospital, Institution or Heritage Commons
ty, Town or Village a Town of Residential Health Care
Ti Street Address condero a
Manner of Death Natural Cause Li Accident ❑Homicide ['Suicide ri❑Undetermined ❑Pending
t Circumstances Investigation
in Medical Certifier Name Title
Richard McKeever M_f)_
iiiiiiiiii Address
102 Race Track Road, Ticonderoga, New York 12883
Death Certificate Filed Town of District Number Register Number
City, Town or Village Ticonderoga 1 564 50
El Burial Date Cemetery or Crematory
❑Entombment 10/18/2016 Pine View Crematory
ffi Address
:::::::::Cremation Queenshury, New York
Date Place Removed
❑Removal and/or Held
and/or Address
h Hold
tEi)
0 Date Point of
to Li Transportation Shipment
G by Common Destination
qi Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
z Permit Issued to Registration Number
ilE Name of Funeral Home Wilcox & Regan funeral home 01 821
iiiiiiiiii Address
11 Algonkin St. , Ticonderoga New York 17883
Name of Funeral Firm Making Disposition or to�Vhom
R• emains are Shipped, If Other than Above
• Address
I
" P• ermission is hereby granted to dispose of the human remain escribed a ve • i +icated.
Eg Date Issued 10/18/2016 Registrar of Vital Statistics 2iT�
(si. - ire)
iiiin
District Number 1 564 Place Town of Ticonderoga
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
III
Date of Disposition ID/lo fr, Place of Dispositionfamti,,,,,..., 6(�m4,,u•,
a, (address)
Ili
CA
CC (section) (lot number) (grave number)
6 Name of Sexton or Person in Charge of Premises /ir,s 304igi
2 (please print)
W. Signature `i Title AL MVO Ile-
(over)
DOH-1555 (02/2004)