Sours Jr, Ralph NEW YORK STATE DEPARTMENT OF HEALTH ' 71(
Vital Records Section - : Burial - Transit Permit
Name First Middle Last Sex
Ralph Day'd Sours, Jr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
October 1 3, 201 5 70 yrs. War or Datt.` �; Pt nam
14 Place of Death Hospital, Institu: 'n or
Town of
City, Town or VillageIII Ticonderoga Street Address Moses-Ludington Hospital
£: Manner of Death u Natural Cause El Accident EI Homicide 0 Suit 'e riUndetermined El Pending
14 Circumstances Investigation
iri Medical Certifier Name Title
Todd R. Waldorf D.O.
Address
1019 Wicker Street, Ticonderoga, NY
Miii Death Certificate Filed Town of District Number Register Number
City, Town or Village Ticonderoga 1 564 55
❑Burial Date Cemetery or Crematory
❑Entombment 10/14/2015 Pine View Cremator
Address
❑X Cremation Queensbury, New York
Date Place Removed
2 Removal and/or Held
❑and/or Address
It Hold
CD
fl Date Point of
nTransportation Shipment
O by Common Destination
Carrier
Date ' Cemetery Address
3❑Disinterment
El Reinterment Date Cemetery Address
Permit Issued to Registration Number
, ; Name of Funeral Home Wilcox & Regan funeral home 01 821
Address
iiig 11 Algonkin St. , Ticonderoga, NY 12883
> `s Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
It
tLI
P` Permission is hereby granted to dispose of the human re ins described above as indicated.
Rill Date Issued 1 0/1 4/201 5 Registrar of Vital Statistics , v."� //}') `G
(signature)
District Number 1 564 Place Town of Ticonderoga
F
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
F I
I� Date of Disposition /c f 15'�1 S Place of Disposition Fiat ✓ au.-
2 (address)
iii
0
IC (section) 4.(lot number) C (grave number)
• Name of Sexton or Person in Ch rge of PremisesSl4$'t
Z dij
( lease print)
Signature Title itrAtiPiL
(over)
DOH-1555 (02/2004)