Kirsner, David NEW YORK STATE DEPARTMENT OF HEALTH5
Vital Records Section / Burial - Transit Permit
Name First Middle Last Sex
David Eugene Kirsner Male
Date of Death Age If Veteran of U.S. Armed Forces,
October 18, 2012 80 yrs. War or Dates Korean War
};- Place of Death Town of Hospital, Institution or
City, Town or Village Ticonderoga Street Address 959 Rte. 9N
WManner of Death El Natural Cause 0 Accident ElHomicide ❑Suicide ❑Undetermined ❑Pending
Ut Circumstances Investigation
I<U Medical Certifier Name;) (c.e. Title
Addresd
G(/ie , _Si, t e! /1 -k0AA, A'-/ /,=, -
Death Certificate Filed Town of TicondercOstrict Number Register Number
City, Town or Village 1 564 Lv 7
0 Burial Date Cemetery or Crematory
../..,
° �j �, Pine View Crematory
El Entombment Address PC VC 1
Cremation Queensbury, New York
Date Place Removed
h_
❑Removal and/or Held
and/or Address
Hold
O Date Point of
Transportation Shipment
G by Common Destination
Carrier
❑Disinterment Date Cemetery Address •
El Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Wilcox & Regan funeral home 01 821
Address
11 Algonkin St. , Ticonderoga, New York 12883
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
" Address
cr
la
Permission is hereby ranted to dispose of the human remains described above as indicated.
Date Issued/0/ Registrar of Vital Statistics 7)-7 ,
(signature)
NA 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 1O-73-jt Place of Disposition "t LV«w C,of nviriva..
2 (address)
Lu
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11 (section) /1 (lot number) (' (grave number)
Cli Name of Sexton or P rson in Char of Premises ci,=ttpL J i.t,il
Z (plee�bse print)
ILI
Signature Title C7L-A0 a
(over)
DOH-1555 (02/2004)
A