Mugford, Robert NEW YORK STATE DEPARTMENT OF HEALTH « `��'
Vital Records Section =a Burial - Transit Permit
Name First Middle Last Sex
Robert Clayton Mugford Male
Date of Death Age If Veteran of U.S. Armed Forces,
09/1 3/201 5 80 yrs. War or Dates 1 958 - 1 963
Place of Death Town of Hospital, Institution or Heritage Commons
W City, Town or Village Ticonderc Street Address R idential Healthr_are
0 Manner of Death 0 Natural Cause Accident Li Homicide ❑Suicide ❑Undetermined ❑Pending
It Circumstances Investigation
W Medical Certifier Name Title
Q Richard McKeever M.D.
Address
1019 Wicker Street, Ticonderoga, New York 12883
Death Certificate Filed Town of District Number Register Number
City, Town or Village Ticonderoga 1 564
El Burial Date Cemetery or Crematory
❑Entombment 09/15/2015 Pine View Crematory
Address
;42Cremation Queensbury, New York
Date Place Removed
g❑Removal and/or Held
and/or Address
ht Hold
N
0 Date Point of
a` Transportation Shipment
Es 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, New York 12883
Ei Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
a Address
CC ll ,�.
9' Permission is hereby granted to dispose of the human remains described above as indicated,
Date Issued 0 9/1 5/201 5 Registrar of Vital Statistics V,�,4�J it • G ~(signature)
District Number 1 564 Place Town of Ticonderoga
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILI Date of Disposition 91 ti(i S Place of Disposition nt V.� Ci' f on u,t„
2 (address)
Lu
to
1c (section) (lot number) (grave number)
CI Name of Sexton or Person in Charge of Premisesiiili-p(�.r S crtgii-
(ple a print)
14 im Signature A: Title illkiv q Vt
(over)
DOH-1555 (02/2004)