Marshall, James NEW YORK STATE DEPARTMENT OF HEALTH -7 3 ZZ
Vital Records Section f Burial - Transit Permit
Name First Middle Last Sex
James Dalgren Marshall Male
Date of Death Age If Veteran of U.S. Armed Forces,
1 0/0 8/2 01 6 73 yrs. War or Dates No
}- Place of Death Hospital, Institution or Heritage Commons
'down of Residential Health Care
LAI City, Town or Village Ticonderoga Street Address
0 Manner of Death®Natural Cause 0 Accident Homicide Suicide Undetermined 0 Pending
to Circumstances Investigation
tu Medical Certifier Name Title
Kathleen P. Huestis M_D_
Address
102 Racetrack Road Ticonderoga, New Yor1 12883.
Ni Death Certificate Filed Town of District Number egister Number
ini City, Town or Village Ticonderoga 1 564
['Burial Date Cemetery or Crematory
October 11 , 2016 Pine View Crematory
[I Entombment Address
❑Cremation Queensbury, New York
Date Place Removed
Z❑Removal and/or Held
and/or Address
i=` Hold
+
0 Date Point of
n"0 Transportation Shipment
0 by Common Destination
Carrier
Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
iiiiiii Permit Issued to Registration Number
Name of Funeral Home Wilcox & Regan funeral home 01 821
<. Address
1 1 Algonkin St- _ Ti rnnrleroga New York 1 2883
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
to
lLI
adi Permission is hereby granted to dispose of the human rem ' s des ribed above as indicated.
ig Date Issued 1 0/1 1 /2 01 6 Registrar of Vital Statistics
(s natur
Ri 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 /�
L Date of Disposition /o�hi/A Place of Disposition Rd()it..% cf rrici0r v_..
2 (address)
LU
t (section) A (lot number) (grave number)
et
a Name of Sexton or Person in Charg of Premises 400091 S-mite
( ease print)
Signature d Title CrkiNtfOe
(over)
DOH-1555 (02/2004)