Keller, Edward NEW YORK STATE DEPARTMENT OF HEALTH 5
Vital Records Section Burial - Transit Permit o
Name First Middle Last Sex
Edward Preston Keller Male
Date of Death Age If Veteran of U.S. Armed Forces,
12/23/2015 74 yrs. War or Dates Vietnam
Place of Death Town of Hospital, Institution or Heritage Commons
2 City, Town or Village Ticonderoga Street Address Residential Healthcare
W Manner of Death Natural Cause Accident ❑Homicide Suicide ❑Undetermined ❑Pending
Circumstances Investigation
iii Medical Certifier Name Title
Richard McKeever M.D.
Address
1019 Wicker Street, Ticonderoga, NY 12883
Death Certificate Filed Town of District Number Register Number
City, Town or Village Ticonderoga 1 564 69
gi! DBurial Date Cemetery or Crematory
12/28/2015 Pine View Crematory
❑Entombment Address
;;;Cremation Queensbury, New York 1243011
Date Place Removed
Z Removal and/or Held
❑and/or
Address F;
Ul
Hold
0 Date Point of
CL 0 Transportation Shipment
C by Common Destination
Carrier
Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Wilcox & Regan funeral home 01 821
Address
11 Algonkin St. , Ticonderoga, NY 12883
II Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
ir
111
` Permission is hereby granted to dispose of the human remains d r)bed abo as i d cated.
Date Issued1 2/2 3/2 01 5 Registrar of Vital Statistics t/ OtV
(signs r )
Aii District Number 1 564 Place Town of Ticondero a
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
i
Z
111 Date of Disposition 12-30-)5 Place of Disposition /r- a u r eij 6c?,m,,74ofy
(address)
tii
tl}
CC (section) \\ (lot number) (grave number)
tz Name of Sexton or rson in Charge of Premises J c,, i re.., I 2 c.4 P
2 (please print)
al
Signature Title L/emala r •
7
(over)
DOH-1555 (02/2004)