Wilcox, Normond NEW YORK STATE DEPARTMENT OF HEALTH , . - '- Burial - Transit �ermit
Vital Records Section
Name First Middle Last Sex
Normond E Wilcox Male
Date of Death Age If Veteran of U.S.Armed Forces, NO
I" February 29, 2012 77 War or Dates
Z Place of Death Hospital, Institution or
W City,Town,or Village Granville Street Address Indian River Rehabilitation and Health C
G Manner of Death ®Natural Cause ❑ Accident ❑Homicide DSuicide 0 Undetermined 0 Pending
W Circumstances Investigation
U Medical Certifier Name Title
W Jennifer Hayes MD
0 Address
17 Madison Street Granville New York 12832
Death Certificate Filed District Number Register Number
City,Town or Village Granville ,,c7a` --- /7
❑Burial Date March 5, 2012 Cemetery or Crematory
Pine View Crematorium
❑Entombment -Address
71 Cremation 21 Quaker Road Queensbury New York 12803
Date Place Removed
0 0 Removal and/or Held
and/or Address
I' Hold
0 Date Point of
0 ❑Transportation Shipment
O. by Common Destination
Carrier
Date Cemetery Address
a ❑Disinterment
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Jillson Funeral Home, Inc. 00885
Address
46 Williams Street, Whitehall, New York 12887
~ Name of Funeral Firm Making Disposition or to Whom
X• Remains are Shipped, If Other than Above
W Address
0.
Permission is her granted to dispose of the human remain descri : abo as indicated.
Date Issued 4 / / Registrar of Vital Statistics ►� /'./ V-�
(signature)
District Number 5 7 5 Place Granvi l le,New York
t- I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2
W Date of Disposition Fkrc'L it /D -Place of Disposition 4?c,t1 &. 640tv,,
2 (address)
W
VI
0 (section) (lot number) (grave number)
00 Name of Sexton or Person in Charge of Pre ' es /hc.os i,.- S wtIt
2 (please print)
W i' L
Signature Title ( ��d{1-
(over)
DOH-1555 (02/2004)