Densmore, Floyd ii
NEW YORK STATE DEPARTMENT OF HEALTH 4 �$`
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Floyd William Densmore Male
Date of Death Age If Veteran of U.S. Armed Forces,
11 /01 /2012 92 yrs. War or Dates W.W. II
I- Place of Death . Town of Hospital, Institution or Heritage Commons
ill City, Town or Village Ticonderoga Street Address Residential Healthcare
Manner of Death b Natural Cause u Accident 0 Homicide El Suicide 0 Undetermined 1---1 Pending
W. CircumstancesInvestigation
ul Medical Certifier Name Title
o Glen Chapman, M.D.
Address
P.O. Box 29, Ticonderoga, NY 12883
Death Certificate Filed Town of 1 District Number Register Number
City, Town or Village Ticonderoga 1 564 72
>ii 0Burial Date Cemetery or Crematory
11 /5/2012 Pine View Crematory
[]Entombment Address
<) Cremation Queensbury, New York
Date Place Removed
Z. Removal and/or Held
❑and/or Address —
U)
Hold
0 Date Point of
tioCL[]Transportation Shipment
C by Common Destination
Carrier
iliiil!El Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
gliiii Permit Issued to Registration Number
Name of Funeral Home Wilcox & Regan funeral home 01821
Address
11 Algonkin St. , Ticonderoga, NY 12883
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
t
f
Permission is hereby granted to dispose of the human remains scribed ab ve as'ndicated.
iilie Date Issued 1 1 /2/201 2 Registrar of Vital Statistics m "L
(si ture)
District Number 1 564 Place Town of Tico ero iii
,,,,.:: I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2 ,�
l Date of Disposition tt 11 I tt Place of Disposition 'PA/�14allipti i
2 (address)
ill
CC (section) (iot number) (grave number)
et Aiti Name of Sexton or Person in Charge of Premisesc:S� .� Stle
eiL
(ple print)
Signature Title CPalwOr 3L
(over)
DOH-1555 (02/2004)