Gilbo Jr, John NEW YORK STATE DEPARTMENT OF HEALTH -Z7J
Vital Records Section Burial - ransit Permit
Name First Middle Last Sex
John Oakley Gilbo, Jr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
03/21 /201 6 91 years War or Dates 1943-1945
Place of Death Hospital, Institution or
Town of p Heritage Commons
uCity, Town or Village Ti r_onc3Proga Street Address Residential Health Care
W Manner of Death E Natural Cause El Accident Q Homicide Suicide Undetermined 0 Pending
Circumstances Investigation
W Medical Certifier Name Title
12 Todd R. Waldorf D.O.
Address
1019 Wicker Street, Ticonderoga, NY 12883
Death Certificate Filed Town of District Number Register N mber
City, Town or Village Ticonderoga 1 564
0 Burial Date Cemetery or Crematory
03/24/2016 Pine View Crematory
El Entombment Address
ID Cremation Oueensbury, New York
Date Place Removed
Z❑Removal and/or Held
2 and/or Address
t= Hold
f)
0 Date Point of
CL
❑Transportation Shipment
Et by Common Destination
Carrier
El Disinterment Date Cemetery Address
L. Reinterment Date Cemetery Address
Permit Issued to Registration Number
`> Name of Funeral Home Wilcox & Regan funeral home 01 821
gili Address
iNi 11 Algonkin St. , Ticonderoga, NY 12883
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
t
i
!: Permission is hereby granted to dispose of the human rem 'n describe bo as indicated.
ilgil Date Issued 3/2 4/2 01 6 Registrar of Vital Statistics
(signature)
District Number 1 564 Place Town of Tic deroqa
'` I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Iii
ILI Date of Disposition 3 f ifi6 Place of Disposition 4i ti-. Cr#Nata`.
2 (address)
ILI
cc (section) . (lot number) (grave number)
Name of Sexton or Person in Charg of Premises Zit) 5ii.w*
2 (pease print)'
Ltt Signature Title 11 ttT74
(over)
DOH-1555 (02/2004)