Fuller, Jr. Frederick NEW YORK STATE DEPARTMENT OF HEALTH - 4f 63
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Frederick Victor Fuller, Jr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
1 0/07/201 2 59 years War or Dates No
Place of Death Town of Hospital, Institution or
City, Town or Village Ticonderoga Street Address Moses-Ludington Hospital
ILIa Manner of Death 0 Natural Cause Accident Homicide D Suicide Undetermined Pending
t Circumstances Investigation
W Medical Certifier Name Title
Pt C. Francis Varga M.D.
Address
P.O. Box 768, Lake Placid, New York 12946
Death Certificate Filed Town of District Number Register Number
City, Town or Village Ticonderoga 1 564 Qc
_< 0 Burial Date Cemetery or Crematory
10/10/2012 Pine View Crematory
> ['Entombment Address
•
Cremation Queensbury, New York
Date Place Removed
Z ❑Removal and/or Held
I and/or Address
.6, Hold
CA
0 Date Point of
At 1=1 Transportation Shipment
0 by Common Destination
iiN Carrier
Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Wilcox & Regan funeral home 01 821
Address
11 Algonkin St. , P.O. Box 543, Ticonderoga, New York 12883
qii Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
c
tit
Permission is hereby granted to dispose of the human re ains described above as indicated.
Date Issued 1 0/1 0/201 2 Registrar of Vital Statistics In ' Gile-es--
(signature)
ip 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:
2 '1 �^
ILI Date of Disposition lobo471m,i'L Place of Disposition Vifi� C. rti...,
(address)
I
#/
LC (section) (tot number) , (grave number)
Name of Sexton or Person in Charge + /
f Premises - n ti.)'l�v l^"��
i f lease print)
41 Signature — Title Cl2 r OL
(over)
DOH-1555 (02/2004)