Default, Earl NEW YORK STATE DEPARTMENT OF HEALTrI 4 (4
Vital Records Section y., Burial - Transit ermit
Name First Middle Last Sex
Fan Au ; P Dufault Male
Date of Death Age If Veteran of U.S. Armed Forces,
09/01 /201 5 57 yrs_ War or Dates Nn
}-• Place of Death Town of Hospital, Institution or
WCity, Town or Village Ti cnndern a Street Address Moses-Ludington Hospital
Q Manner of Death®Natural Cause U Accident ❑Homicide ❑Suicide ❑Undetermined 0 Pending
Ltd Circumstances Investigation
W Medical Certifier Name Title
Q C. Francis Varga M.D.
Address
P.O. Box 768, Lake Placid, New York 12946
Death Certificate Filed Town of District Number Register Number
City, Town or Village Ticonderoga 1 564 48
❑Burial Date Cemetery or Crematory
❑Entombment 09/08/2015 Pine View Crematory
Address
®Cremation Oueensbury, New York
Date Place Removed
Z ❑Removal and/or Held
14r3 and/or Address
H Hold
U)
0 Date Point of
R Transportation Shipment
0 by Common Destination
Carrier
El Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
imi Name of Funeral Home Wilcox & Regan funeral home 01 821
Address
11 Algonkin St. , Ticonderoga, NY 12883
Nii Name of Funeral Firm Making Disposition or to Whom
14. Remains are Shipped, If Other than Above
Address
ILI
it
1 Permission is hereby granted to dispose of the human rema' escribed a ove as. icated.
Date Issued 09/0 2/201 5 Registrar of Vital Statistics
(sin ure)
District Number 1 564 Place Town of Tico deroga
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
II,,
P 9�WljC Dispositiong V 7
Date of Disposition Place of ,.� ,,, ,�..� pr,✓�
(address)
Lf1
fa
g (section) (lot number) (grave number)
Ciz Name of Sexton or Perso in Char a of Premises rip VI, .3(Please print)
Signature Title PA f e
(over)
DOH-1555 (02/2004)