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Riper Jr, George NEW YORK STATE DEPARTMENT OF HEALTH At. Tio Vital Records Section ,,: . . , Burial - Transit Permit Name First Middle Last Sex GPorgP J_ Ri e Jr. Male Date of Death Age If Veteran of U.S. Armed F ofces, Oi 10/16/2015 65 "yrs. War or Dates No j-: Place of Death Town of Hospital, Institution or X City, Town or Village m de Street Address 38 Park Avenue IJl i�iararaga ti Manner of Death Natural Cause ❑Accident ❑Homicide ®Suicide El❑Undetermined ❑Pending Illy Circumstances Investigation jj Medical Certifier Name Title 14, C. Francis Varga M_n Address P.O. Box 768, Take Placid, NPw York 1294 Death Certificate Filed Town of District Number Register Number City, Town or Village rri conderoga 154 57 ❑Burial Date Cemetery or crematory 10/27/2015 Pine View Crematory 0 Entombment Address iiip©Cremation Queensbury, New York Date Place Removed Z❑Removal and/or Held and/or Address g Hold 9 Date Point of vi❑Transportation Shipment La by Common Destination Carrier Disinterment Date Cemetery Address Reinterment Date Cemetery Address igiii Permit Issued to Registration Number Bil Name of Funeral Home Wilcox & Regan funeral home 01 821 Address igiii 11 Algonkin St. , Ticonderoga, New York 12883 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above • Address Ce iti t Permission is hereby granted to dispose of the human rema"7Ifi d scribed ve a, "ndicated. Date Issued 1 0/2 6/2 01 5 Registrar of Vital Statistics / / .:,::::::- t ( ,'re) District Number 1 564 Place Town of Ticon eroga ,;_::.> I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: 2 ILI Date of Disposition /p/2sj,T Place of Disposition .J' rft.floer,w (address) w (11 CC (section) 4 (lot number) (grave number) 0 fa Name of Sexton or Person in Charge of Premises L 4:- Same( please print) Iii. Signature Title *- (over) DOH-1555 (02/2004)