Secone, Tobia NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Tnhia J_ Secone Male
Date of Death Age If Veteran of U.S. Armed Forces,
07/1 5/201 4 90 yrs. War or Dates W.W.II, Korean War
I- Place of Death Town of Hospital, Institution or
WCity, Town or Village Ticonderoga Street Address N.Y.S. Rte. 74
p Manner of Death❑Natural Cause gAccident 111 Homicide 0 Suicide riUndetermined El Pending
Circumstances Investigation
W Medical Certifier Name Title
CI C. Francis Varga M.D.
Address
P-O_ Rox 768, Take Placid, NY 12946
Death Certificate Filed Town of District Number Register Number
City, Town or Village Ticonderoga 1 564
❑Burial Date Cemetery or Crematory
07/21 /2014 Pine View Crematory
❑Entombment Address
®Cremation Queensbury, New York
Date Place Removed
Z ri Removal and/or Held
2 and/or Address
H Hold
ih
0 Date Point of
es ❑Transportation Shipment
L3 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
Cr
W
Permission is hereby granted to dispose of the human re i d cribed a o as i di ated.
Date Issued 0 7/1 8/201 4 Registrar of Vital Statistics i A,b Yi/1:y_Wti�
(sig tur
Ei District Number 1 564 Place Tow of Tico eroga
;a.:: I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
la t-
Date of Disposition )-22-19 Place of Disposition CC gc zu�
(address)
111
Ott
te (section) /� (lot numbr) �i` (grave number)
0
Name of Sexton or Person in Charge of Premises t� �M"T
Z. it: (please print)
Lu Signature LTitle " -
(over)
DOH-1555 (02/2004)