Hopkins, Jr. Daniel NEW YORK STATE DEPARTMENT OF HEALTH `f - 1 # 413
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Daniel Joseph Hopkins, Jr. Male
gi Date of Death Age If Veteran-of U.S. Armed Forces,
aii 0 8/0 7/201 2 67 y r s. War or Dates No
Place of Death Town of Hospital, Institution or Heritage Commons
taZ City, Town or Village Ticonderoga Street Address Residential Healthcare
• Manner of Death 12uNatural Cause El Accident 0 Homicide 0 Suicide 0 Undetermined ri Pending
Circumstances Investigation
ill Medical Certifier Name Title
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 '3
0❑Burial Date Cemetery or Crematory
08/09/2012 I Pine View Crematory
` ❑Entombment Address
"; ®Cremation Queensbury, New York
Date Place Removed
Z Removal and/or Held
❑and/or Address
laM Hold
O Date Point of
ti El Transportation Shipment
G by Common Destination
Carrier
Q Disinterment Date Cemetery Address
liEiQ Reinterment Date Cemetery Address
Illii Permit Issued to Registration Number
Mi Name of Funeral Home Wilcox & Regan funeral home 01 821
Address
11 Algonkin St. , P.O. Box 543, Ticonderoga, New York 12883
Name of Funeral Firm Making Disposition or to Whom
# Remains are Shipped, If Other than Above
• Address
te
its
"` Permission is hereby granted to dispose of the human rem 'ns described above as indicated.
Date Issued 08/0 9/201 2 Registrar of Vital Statistics 'In- C2-i` - --
(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:
W Date of Disposition 8-10-11 Place of Disposition &f& Uicu Cro►dt&r.ut:
(address)
LEI
ta
Cc (section) (lot number) (grave number)
ci Name of Sexton or Person in Char a of Premises 116 t'l� r` 3 e�.4.
lease print)
Signature tu G'f Title (ILL Mk-Ad
(over)
DOH-1555 (02/2004)