Winchell Jr, Raymond NEW YORK STATE DEPARTMENT OF HEALTH
if 3i.
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Raymond Arthur - Winchell Jr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
1 1 /23/201 4 68 yrs . War or Dates Vietnam War
Place of Death Town of Hospital, Institution or
W City, Town or Village Ti con ieroga Street Address Moses-Ludington Hospital
ci Manner of Death f-1 Natural Cause 0 Accident 0 Homicide Suicide Undetermined Pending
W I4 Circumstances Investigation
W Medical Certifier Name Title
d Todd R. Waldorf D.O.
Address
1019 Wicker Street, Ticonderoga, NY 12883
Death Certificate Filed Town of District Number Register Number
:•- City, Town or Village Ticonderoga 1 564 62
❑Burial Date Cemetery or Crematory
❑Entombment 11 /25/201 4 Pine View Crematory
Address
®Cremation Queensbury, New York
Date Place Removed
Z ❑Removal and/or Held
2 and/or
F Address
N Hold
0 Date Point of
• ❑Transportation Shipment
C1 by Common Destination
Carrier
Disinterment Date Cemetery Address
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
Remains are Shipped, If Other than Above
2 Address
tr
W
• Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 1 1 /25/201 4 Registrar of Vital Statistics ,1, ) n) • GC L ��
(signature)
District Number 1 564 Place Town of Ticonderoga
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILI Date of Disposition I Z-3-14 Place of Disposition 704.0 _ Cr:4--elor..- ,
12 (address)
Cl)
CC (section) A (lot number) (grave number)
ci Name of Sexton or Perso in Charge of Premises ! `,'+t7� - u '"
r (pl ase print)
• Signature Title CILCOlikrk
(over)
DOH-1555 (02/2004)