Marriott, Daniel RL)
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Daniel Francis Marriott Male
Date of Death Age If Veteran of U.S. Armed Forces,
12/10/2016 66 years War or Dates
Place of Death Hospital, Institution or
City, ToDQXXKVX4 X X Saratoga Springs Street Address Saratoga Hospital
Manner of Death riklatural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined Pending
Circumstances Investigation
ui Medical Certifier Name Title
Qiong Wang M D
Address
211 Church St, Saratoga Springs, New York
Death Certificate Filed District Number Register Number
City, To*Xa6XVAI XX Saratoga Springs 4501 583
❑Burial Date Cemetery or Cremator"
12/13/2016 Pine View Cemetnn
❑Entombment Address
[cremation Queensbury N Y
Date Place Removed
Z- Removal and/or Held
0 and/or -
Address
#/)
Hold
C? Date Point of
toTransportation Shipment
Li
G3 by Common Destination
Carrier
❑Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Wilcox& Regan 01821
Address
11 Algonkin St. , Ticonderoga NY 12883
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
Ui
a` Permission is hereby granted to dispose of the human re ' s c ed MO indica d.
Date Issued 12/13/2016 Registrar of Vital Statistics
(signature)
District Number 4501 Place Saratoga Springs
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
t1 t Date of Disposition /2//3 Ct, Place of Disposition Pi ;/ Q,,,f C le:try
2 l (address)
LLI
U,
CC (section) (lot number) (grave number)
pName of Sexto r Pe on i Charge of Premises Ju l;z. .� 19/: e-4.€
(please print)
Signature Title e-rt n40,4,r-
(over)
DOH-1555 (02/2004)