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St. Louis, Dale NEW YORK STATE DEPARTMENT OF HEALTH - - 1 q0 1 Vital Records Section Burial - Transit Permit Name First Middle Last Sex DALE W. ST. LOUIS MALE Date of Death Age If Veteran of U.S. Armed Forces, NOVEMBER 3, 2015 83 War or Dates 1949-1952 .1r- Place of Death Hospital, Institution or City, Town or Village CITY OF PLATTSBURGH Street Address CVPH MEDICAL CENTER tij0 Manner of Death©Natural Cause 0 Accident El Homicide ❑Suicide El Undetermined ❑Pending Lf Circumstances Investigation W Medical Certifier Name Title a GEORGE CIOLAC MD Address PLATTSBURGH, NY Death Certificate Filed District Number Register umber City, Town or Village CITY OF PLATTSBURGH 901 i. 5L. ❑Burial 1 Date Cemetery or Crematory NOVEMBER 6, 2015 PINE VIEW CREMATORY ❑Entombment Address ;i;;;®Cremation QUEENSBURY, NY Date Place Removed Z�Removal and/or Held 2 and/or Address F_ Hold N 0 Date Point of goilL❑Transportation Shipment _ _ a by Common Destination iNii Carrier Disinterment Date Cemetery Address Renterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home WILCOX & REGAN 01821 Address 11 ALGONKIN STREET, TICONDEROGA, NY 12883 Name of Funeral Firm Making Disposition or to Whom lii Remains are Shipped, If Other than Above ;'; Address CC LU II` Permission is hereby granted to dispose of the human remains descri ed a ve as Indic ed. Date Issued NOV 5, 2015 Registrar of Vital Statistics .11/ ` L '`ftelli (signature) District Number 901 Place CITY OF PLATTSBURGH I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: t LU Date of Disposition Oil/5- Place of Disposition utt.V-4 6 ors 2 (address) W CC (section) (lot number) (grave number) ci Name of Sexton or Person in Charg of Premises tl Sows' Z (please print) :,:::,„„ Signature A - Title - mttlki- (over) DOH-1555 (02/2004)