Fuller, Leo NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
t o near cli= Fuller Male
. Date of Death Age if Veteran of U.S. Armed Forces,
January 17, 2016 81 yrs. War or Dates 1 952-1 959 _
1-. Place of Death Town of Hospital, Institution or
City, Town or Village Ti condpso•a Street Address 25 Killicut Mountain Road
Manner of Death®Natural Cause El Accident Homicide u Suicide 0 Undetermined ri Pending
Iii Circumstances Investigation
tu Medical Certifier Name Title
Glen Chapman M.D.
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
[]Burial Date Cemetery or Crematory
QEntombment 1 /21 /201 6 Pine View Crematory
€<> Address
®Cremation Queensbury, New York
Date Place Removed
. Removal and/or Held
C ❑and/or
F-, Address
—CO
Hold
O Date Point of
Q Transportation Shipment
0 by Common Destination
Carrier
Disinterment Date Cemetery Address
LI Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Wilcox & Regan funeral home 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
it
ILI
Permission is hereby granted to dispose of the human remain d scribed ov s indicated.
Date Issued 1 /20/201 6 Registrar of Vital Statistics oeo-,
nature)
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:
Ili Date of Disposition I /24')jjPlace of Disposition D
'4� u� Crrm.�pr�
Ili
(address)
to
IX (section) (lot number) (grave number)
0
CI Name of Sexton or Person in Charge of Premises is . twQtl
(p ase print)
la
Signature 71 Title ekidlipit
(over)
DOH-1555 (02/2004)