Cooper, Roland NEW YORK STATE DEPARTMENT OF HEALTHY 4N
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Roland Henry Cooper Male
Date of Death Age If Veteran of U.S. Armed Forces,
8/26/2012 88 yrs. War or Dates 1943-1945
1-4 Place of Death Town of Hospital, Institution or Heritage Commons
6 City, Town or Village Ticonderoga Street Address Residential Healthcare
a Manner of Death 0 Natural Cause Accident 0 Homicide Suicide ❑ Undetermined ❑Pending
W Circumstances Investigation
ill Medical Certifier Name Title
Q Glen Chapman M .D.
Address
P.O. Box 29, Ticonderoga, New York 12883
Death Certificate Filed Town of District Number Register Number
City, Town or Village Ticonderoga 1 564 q k
Burial Date Cemetery or Crematory
8/28/2012 Pine View Crematory
❑Entombment Address
®Cremation Queensbury, New York
Date Place Removed
9C �Removal and/or Held
and/or Address
i= Hold
ID
Date Point of
i Transportation Shipment
Gs by Common Destination
Carrier
Disinterment Date Cemetery Address
Date Cemetery Address
El Reinterment
ni Permit Issued to Registration Number
Name of Funeral Home Wilcox & Regan Funeral Home 01 821
iia Address
iiil 11 Algonkin St. , P.O. Box 543, Ticonderoga, NY 12883
Name of Funeral Firm Making Disposition or to Whom
;- Remains are Shipped, If Other than Above
a Address
tr
ILE
,1 Permission is hereby granted to dispose of the human remain described above as indicated.
Date Issued 8/28/2012 Registrar of Vital Statistics , G .L-f--
7 (signature)
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:
ILI Date of Disposition q-1FiL Place of Disposition .P,.�,0u,a �rtw�
(address)
Ili
tO
re (section) (lot number) (grave number)
0
Name of Sexton or Person in Charg of Premises r/Skis S wfF1-
ihrL i+ (please print]
Signature Title Crt M Y (L
(over)
DOH-1555 (02/2004)