Vradenburg, Edward 1
NEW YORK STATE DEPARTMENT OF HEALTH 14
Vital Records Section 1 Burial - Transit Permit
: Name First Middle Last Sex
Edward L. Vradenburg Male
Date of Death Age If Veteran of U.S. Armed Forces,
Ri 02/21 /2014 77 yrs. War or Dates No
M- Place of Death Town of Hospital, Institution or
ommons
City, Town or Village Ticonderoga Street Address ResHidentalritage CHealthcare
0 Manner of Death®Natural Cause El Accident El Homicide El Suicide ❑Undetermined ❑Pending
lilCircumstances Investigation
iii Medical Certifier Name Title
0 Toni Sturm M.D.
Address
1019 Wicker Street, Ticonderoga, NY 12883
Death Certificate Filed Town of District Number Register Number I I
City, Town or Village Ticonderoga 1 564
❑Burial Date Cemetery or Crematory
['Entombment Pine View Crematory
Address
acremation - Queensbury, New York
Date Place Removed
Z❑Removal and/or Held
and/or Address
F= Hold
0 Date Point of
.toilt ❑Transportation Shipment
CZ by Common Destination
gi 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
ni 11 Algonkin St. , Ticonderoga, NY 12883
II Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
It
i
fl` Permission is hereby granted to dispose of the human remai cribed a ve indicated.
iin Date Issued 02/24/201 4 Registrar of Vital Statistics
(si na ure)
District Number 1 564 Place Town of Tic deroga
Iiig
N
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Ili Date of Disposition in by Place of Disposition g•A)44.> �.,, ter.....
(address)
lit
CC (section) (lot number (grave number)
a
ti Name of Sexton or Perso in Charge f Premises ! 14 S ,�A-ttt
Z (pl ase print)
iii
Signature Cya1. Title L7Jh
(over)
DOH-1555 (02/2004)