Wright, Ivan II-
NEW YORK STATE DEPARTMENT OF HEALTH s
Vital Records Section ,*,-,-.:1, .
o Burial - Transit Permit
Name First Middle Last Sex
Ivan Atf rpd Writ-flit Male
Date of Death Age If Veteran of U.S. Armed orces,
08/06/2015 94 yrs. War or Dates No
16 Place of Death Hoital, Institution or
City, Town or Village Town of
Ticonderoga Street Address Moses-Ludington Hospital
a Manner of Death®Natural Cause ❑Accident ❑Homicide 0 Suicide 0 Undetermined El Pending
Li/ Circumstances Investigation
iii Medical Certifier Name Title
0 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 T i rnn P g 42
/Burial Date d ro a Cemetery orr crematory
['Entombment08/07/201 5 Pine View Crematory
Address
['Cremation Queensbury, New York
Date Place Removed
Z ❑Removal and/or Held
2 and/or Address
t Hold
0 Date Point of
S 0 Transportation Shipment
0 by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Q 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
.i Remains are Shipped, If Other than Above
Address
ILI
CL
Permission is hereby granted to dispose of the human re ains described above as indicated.
Date Issued 0 8/0 7/201 5 Registrar of Vital Statistics L. . ,22.4-4----74--/
(signature)
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:
111 Date of Disposition $_r t((l c Place of Disposition �['+VI Cr fipr .-k
(address)
Ili
CO
ICE (section) /, (lot numb (grave number)
Name of Sexton or Person in Charge of Premises L htiI i
(please print)
Signature U 1. Title /0,14i uIA
(over)
DOH-1555 (02/2004)