Schryer, Bernard NEW YORK STATE DEPARTMENT OF HEALTH r
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Bernard F. Schryer Male
Date of Death Age If Veteran of U.S. Armed Forces,
January 16, 2015 86 yrs. War or Dates 1 944-1 946
1 Place of Death Town of Hospital, Institution or
ZCity, Town or Village Ticonderoga Street Address 1 2 Lonergan Lane
0 Manner of Death E Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
ILI Circumstances Investigation
w Medical Certifier Name Title
a Glen Chapman M.D.
Address
P.O. Box 29, Ticonderoga, NY 12883
Death Certificate Filed Town of District Number Register Number
City, Town or Village Ti cnndPrnga 1 564 4
❑Burial Date Cemetery or Crematory
Ad
❑Entombment 1 /21dress/201 5 Pine View Crematory
❑X Cremation Queensbury, New York
Date Place Removed
❑Removal and/or Held
and/or Address
- Hold
IA
Date Point of
CL
t��
Transportation Shipment
0 by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
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
l
LI
` Permission is hereby granted to dispose of the human re - d-scribed ab ve - - i dicated.
Date Issued 1 /1 9/2 01 5 Registrar of Vital Statistics ` '
(sig - re)
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 /zf Ay Place of Disposition 'Etc (IL Crh-elor, -
(address)
Lu
to
11 (section) g (lot number (grave number)
Ci Name of Sexton or Pers rn in Ch rge of Premises r4 L
Z (ease print)
Signature Title 41
(over)
DOH-1555 (02/2004)