Quoos, Alan NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section c - Burial - Transit Permit
Name First Middle Last Sex
Alan Frederick Quoos Male
Date of Death Age ( Veteran of U.S. Armed Forces,
0 9/0 3/2 01 5 81 y r s: War or Dates No
- Place of Death Town of Hospital, Institution or
City, Town or Village Crown Point Street Address 6 Berry Patch Lane
111
Manner of Death Natural Cause O Accident El Homicide O Suicide O Undetermined El Pending
Circumstances Investigation
W Medical Certifier Name Title
0 Glen Chapman M.D.
Address
P.O. Box 29, Ticonderoga, NY 12883
ni Death Certificate Filed Town of District Number Register Number
City, Town or Village Crown Point 1 551 5
!i:li OBurial Date Cemetery or Crematory
09/08/2015 Pine View Crematory
< OEntombment Address
UCremation Queensbury, New York
Date Place Removed
Z❑Removal and/or Held
and/or Address
F= Hold
fin
0 Date Point of
Transportation ' Shipment
0 by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Date Cemetery Address
El Reinterment
` r Permit Issued to Registration Number
Name of Funeral Home Wilcox & Regan funeral home 01 821
:: Address
11 Algonkin St. , Ticonderoga, New York 12883
Pli Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
t
ll .
9' Permission is hereby granted to dispose of the human re ' s d cr bed ve s i is ed.
Date Issued 09/0 4/201 5 Registrar of Vital Sta- tics
(signature)
District Number /5T5 ) Place Town of Crown Point
.` I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k � 1
la Date of Disposition 9'S',5 Place of Disposition 4t V•w 114fIc.
2 (address)
w
0
CC (section) (lot nu ber) (grave number)
pName of Sexton or Person in Char of Premises ,• �W
z- 4 (please print)
Signature Title trat
(over)
DOH-1555 (02/2004)