Wiles, John A 3S2
NEW YORK STATE DEPARTMENT OF HEALTH.
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
John Cole wi1PS Male
Date of Death Age If Veteran of U.S. Armed Forces,
05/30/2014 89 yrs. War or Dates W.W.II
I Place of Death Town of Hospital, Institution or
Z City, Town or Village Ticonderoga Street Address 41 Treadway Street
11.1
Manner of Death 0 Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
ILICircumstances Investigation
tu Medical Certifier Name Title
II Glen Chapman M.D.
Address
P.O. Box 29, Ticonderoga NY 128A-4
Death Certificate Filed Town of District Number Register Number
City, Town or Village Ticonderoga 1 564 28
❑Burial Date Cemetery or Crematory
;< ❑Entombment 06/03/201 4 Pine View Crematory
Address
®Cremation Queensbury, NPw York
Date Place Removed
Z ❑Removal and/or Held
9 and/or Address
1=` Hold
Date Point of
Transportation Shipment
0 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
1- Remains are Shipped, If Other than Above
Address
CC
IEl
Permission is hereby granted to dispose of the human remai s escribed ove as dicated.
Date Issued 0 6/0 2/2 01 4 Registrar of Vital Statistics .t,, d
-g 4 e)
District Number 1 564 Place Town of Ticonderoga
1
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
la Date of Disposition 6/s/pf Place of Disposition .— u,J 60ticfOr3y+�
2 (address)
UEi
ta
CC (section) (lot numbe - (grave number)
ci Name of Sexton or Per n in Char a of Premises il a'ir" �. fait'
Z lease pnn
Signature Title CO iiittrat
(over)
DOH-1555 (02/2004)