Jones, Sloan NEW YORK STATE DEPARTMENT OF HEALTH # l
Vital Records Section Burial - Transit Permit
li Name First Middle Last Sex
Sloan Bobby Jones Male
Date of Death Age If Veteran of U.S. Armed Forces,
06/12/2016 80 yrs. War or Dates 1953 - 1959
} Place of Death Town of Hospital, Institution or
City, Town or Village Ticonderoga Street Address 23 Ell Street
ILIManner of Death 0 Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
W Circumstances Investigation
w Medical Certifier Name Title
0 Todd R_ Waldorf D 0_
Address
Ticonderoga Health Center, Ticonderoga, NY 12883
Death Certificate Filed Town of District Number Register Number zi
City, Town or Village Ticonderoga 1 564
❑Burial Date Cemetery or Crematory
06/14/2016 Pine View Crematory
i ❑Entombment Address
®Cremation Queensbury, New York
r4
Date Place Removed
❑Removal and/or Held
and/or
P Address
Hold
Date Point of
❑Transportation Shipment
G by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
il 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
2
lit
fl' Permission is hereby granted to dispose of the human rem 'ns described above as indicated.
iii Date Issued 6/1 4/201 6 Registrar of Vital Statistics �' d111.2t--)
(signature)
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:
ILI Date of Disposition GC(&lify Place of Disposition 1 .t -J 41+41.,,,-
(address)
LU
CC (section) (lot n ber) (grave number)
cl Name of Sexton or Person in Charge o Premises /1`
( kr nt)5(
Z
phase pri
W.
!liSignature
Titled
(over)
DOH-1555 (02/2004)