Quesnel, Douglas A 27 if
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
•
Name First Middle Last Sex
Douglas Stewart Quesnel Male
Date of Death Age If Veteran of U.S. Armed Forces,
04/08/2015 71 yrs. War or Dates 1965-1967
Place of Death Town of Hospital, Institution or
illCity, Town or Village Ticonderoga Street Address Moses-Ludington Hospital
Manner of Death❑X Natural Cause ❑Accident ❑Homicide ❑Suicide El Undetermined El Pending
Circumstances Investigation
jj Medical Certifier Name Title
C} Glen Chapman M.D.
Address
P.O. Box 29, Ticonderoga, New York 12883
Death Certificate Filed Town of District Number Register Number
City, Town or Village Ticonderoga 1 564 17
>»['Burial Date Cemetery or Crematory
❑Entombment 04/10/2015 . Pine View Crematory
Address
®Cremation Queensbury, New York
Date Place Removed
Z Removal and/or Held
9 ❑and/or
Address
Cl) Hold
0 Date Point of
❑Transportation Shipment
0 by Common Destination
Carrier
ai Q Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
mi LiMi Permit Issued to Registration Number
ii!ii': Name of Funeral Home Wilcox & Regan funeral home 01 821
Address
11 Algonkin St. , Ticonderoga, NY 12883
ill Name of Funeral Firm Making Disposition or to Whom
! Remains are Shipped, If Other than Above
Address
LU.
9' Permission is hereby granted to dispose of the human remai cribed ab as ' 'c ted.
gig Date Issued 04/10/2015 Registrar of Vital Statistics , ` 01A.1 '`'L--
c
(signs re
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 i't))c' Place of Disposition 'et (
2 (address)
la
c (section) 4 (lot number) _. (grave number)
Name of Sexton or Person in Charge of Premises —3/4.,,
(Tease print)
ig
iiN Signature t Title CA A#
(over)
DOH-1555 (02/2004)