Avery, Richard NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Richard Douglas Avery Male
iiiiiiii Date of Death Age .. If Veteran of U.S. Armed Forces,
July 26, 2016 72 yrs. War or Dates 1 962-1 965
-- Place of Death Town of Hospital, Institution or
= City, Town or Village Street Address 2 Lonergan Lane
Ticonderoga
a Manner of Death a Natural Cause 0 Accident 0 Homicide 0 Suicide 0Undetermined 0 Pending
tii Circumstances Investigation
tg Medical Certifier Name Title
Glen Chapman M.D.
Address
102 Race Track Road, Ticonderoga, NY 12883
iel Death Certificate Filed Town of District Number Register Number
City, Town or Village Ticonderoga 1 564
N❑Burial Date Cemetery or Crematory
❑Entombment 7/28/2016 Pine View Crematory
Address
iiiii®Cremation Queensbury, New York
Date Place Removed
❑Removal and/or Held
opii and/or Address
t HHold
5 Date Point of
0.tL Transportation Shipment
G by Common Destination
gi Carrier
❑Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
m LiPermit Issued to Registration Number
Name of Funeral Home Wilcox & Regan funeral home 01 821
iiN Address
im 11 Algonkin St. , Ticonderoga, New York 12883
iiR Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
at
ILI
Permission is hereby granted to dispose of the human rem - d scribed ab ye as ' dicated.
Date Issued 7/2 7/2 01 6 Registrar of Vital Statistics y
si. - re
It 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:
Z
t Date of Disposition 7 I IS[jl� Place of Disposition '�cU t r � �
(address)
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fll
CC (section) /// (lot numb ) (grave number)
CI Name of Sexton or Person in Charge of Premises `riiu 3vs4
please print) n,
la Signature a Title cimm fZVt
(over)
DOH-1555 (02/2004)