Thompson, Jon It 105
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Jon Michael Thompson Male
Date of Death Age If Veteran of U.S. Armed Forces,
02/13/2014 62 yrs. War or Dates No
F Place of Death Town of Hospital, Institution or
Z City, Town or Village Ticonderoga Street Address 62 Water Street
Manner of Death Natural Cause ❑Accident ❑Homicide ❑Suicide 0 Undetermined ❑Pending
1t Circumstances Investigation
• Medical Certifier Name Title
Peter M. Sayers M.D.
Address
17 Miller Drive, Crown Point, NY 12928
Death Certificate Filed Town of District Number Register Number
City, Town or Village Ticonderoga 1 564
❑Burial Date Cemetery or Crematory
❑Entombment 02/17/2014 Pine View Crematory
Address
;;;;;;Cremation Queensbury, New York
Date Place Removed
❑Removal and/or Held
160 and/or Address
E Hold
C
O 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
Remains are Shipped, If Other than Above
• Address
ILJ
Permission is hereby granted to dispose of the human remain ibed above in ated.
Date Issued 0 2/1 4/2 01 4 Registrar of Vital Statistics
( ture)
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:
1LI• Date of Disposition Place of Disposition
(address)
LU
ta
CC (section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises
(please print)
• Signature Title
(over)
DOH-1555 (02/2004)