Cross Jr, Calvin NEW YORK STATE DEPARTMENT OF HEALTH +., # or
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Calvin W. Cross, Jr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
06/04/2015 70 yrs. War or Dates No
Place of Death Town of Hospital, Institution or
City, Town or Village Ticonderoga Street Address 6 Wiley Street
W Manner of Death g3 Natural Cause 0 Accident 0 Homicide Suicide Undetermined Pending
Circumstances Investigation
ut Medical Certifier Name Title
J. Gabler RPA-c
Address
Ticonderoga-Health Center, Ticonderoga, NY 12883
Death Certificate Filed Town of District Number Register Number
City, Town or Village Ticonderoga 1 564 35
['Burial Date Cemetery or Crematory •
06/08/2015 Pine view Crematory
['Entombment Address
MI®Cremation Queensbury, New York
Date Place Removed
❑Removal and/or Held
and/or Address
W
Hold
O Date Point of
IL
❑Transportation Shipment
E by Common Destination
iin Carrier
Q Disinterment Date Cemetery Address
Q Reinterment
Date Cemetery Address
Permit Issued to Registr ti$o Number
;< Name of Funeral Home Wilcox & Regan funeral home
Address
11 Algonkin St. , Ticonderoga, NY 12883
Name of Funeral Firm Making Disposition or to Whom
}- Remains are Shipped, If Other than Above
• Address
f
` Permission is hereby granted to dispose of the human r - s describe ove a dicated.
Date Issued 6/5/201 5 Registrar of Vital Statistics t.I _ `--�f�(� fY\
(sign re) V
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
Iii Date of Disposition is(Ili( Place of Disposition g-4().../ �+ tso:k_
2 (address)
Ui
LC (section) / (lot number) _ (grave number)
Name of Sexton or Person in Charge of Premises G�- i-�- -�c
", /„ please print)
14 Signature Title figwittrk
mii
(over)
DOH-1555 (02/2004)