Burroughs Sr, Harold NEW YORK STATE DEPARTMENT OF HEAL I'I�
Vital Records Section Burial - Transit Permit
Ei Name First Middle Last Sex
Harold James Burroughs, Sr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
04/02/2015 76 yrs. War or Dates No
Place of Death Town of Hospital, Institution or
CityILI , Town or Village Crown Point Street Address 228 Hogan Hill Road
a Manner of Death Natural Cause ❑Accident Ell Homicide ❑Suicide ❑Undetermined ❑Pending
ilk Circumstances Investigation
1t Medical Certifier Name Title
1 Kathleen Huestis M.D.
Address
102 Race Track Road, Ticonderoga, NY 12883
Death Certificate Filed Town of District Number Register Number C
Eiiig City, Town or Village Crown Point 1 551
❑Burial Date Cemetery or Crematory
04/03/2015 Pine view Crematory
❑Entombment Address
Hi®Cremation Queensbury, New York
Date Place Removed
❑Removal and/or Held
and/or
� Address
Hold
th
O Date Point of
tl�5❑Transportation Shipment
0 by Common Destination
Bi Carrier
❑Disinterment Date Cemetery Address
l!ni❑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
Name of Funeral Firm Making Disposition or to Whom
1 . Remains are Shipped, If Other than Above
Address
I
Cr
ti
itL
Permission is hereby granted to dispose of the human remain e ,'bed a s in d.
ieii Date Issued 04/03/2015 Registrar of Vital Sta . - s
(signature)
inii District Number /6-6-1 Place -To w n -F 0 r0 w n I)(9 is n .f-
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
ILI Date of Disposition tit bi(c. Place of Disposition giuk.., 6. -to-o-
(address)
W
Mt
IC (section) I (lot.number) (grave number)
CI Name of Sexton or Person in Charge of remises f
/ . (ease print)
iii
iiilg Signature 4 Title (zPN!'ia`,
(over)
DOH-1555 (02/2004)