Burdick, Stanley NEW YORK STATE DEPARTMENT OF HEALTH 0
Vital Records Section Burial - Transit Permit
;; Name First Middle Last Sex
Stan1 Py Brooks_ Burdick Male
Date of Death Age If Veteran of U.S. Armed Forces,
4/2 2/2 01 6 90 yrs. War or Dates No
Place of Death Town of Hospital, Institution or Heritage Commons
City, Town or Village Ticonderoga Street Address Residential Health Care
a Manner of Death1771w Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
in Circumstances Investigation
la Medical Certifier Name Title
C Todd R. Waldorf D.O.
Address
1019 Wicker Street, Ticonderoga, NY 12883
Death Certificate Filed Town of District Number Register Number
City, Town or Village Ticonderoga 1 564 02 /
❑Burial Date Cemetery or Crematory
4/26/2016 Pine View Crematory
mi['Entombment Address
;;;;cremation Queensbury, New York
Date Place Removed
Z ❑Removal and/or Held
2 and/or Address
H Hold
CD
O Date Point of
'isTransportation Shipment
1?
L1 by Common Destination
Ea Carrier
❑Disinterment Date Cemetery Address
iiiiiii❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
iliiiiiiii Name of Funeral Home Wilcox & Regan funeral home 01 821
gip Address
11 Algonkin St. , Ticonderoga, NY 12883
1111 Name of Funeral Firm Making Disposition or to Whom
• Remains are Shipped, If Other than Above
• Address
tt
Permission is hereby granted to dispose of the human remains described above as indicated.
liiiiiiii Date Issued 4/2 5/2 01 6 Registrar of Vital Statistics 446&,,t) (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:
k ( I
to Date of Disposition 9 f/1 iu6 Place of Disposition 0,.../ Gµ o,—.
2 (address)
UI
CO
CC (section) i (lot number) (grave number)
ci Name of Sexton or Person in Char a of Premises t '�'r L Ser-Pord
z please print)
Signature (it Title CfrINTOC
(over)
DOH-1555 (02/2004)