Jacques Jr, Theodore t is 1 it�0S--
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Theodore ,Tosenh Jacques, Jr. Male
• Date of Death Age - If Veteran of U.S. Armed Forces,
03/25/2014 87 War or Dates Korean War
w- Place of Death Town of Hospital, Institution or
6 City, Town or Village Ticonderoga Street Address 247 Black Point Road
3 Manner of Death 6 Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Ili Circumstances Investigation
Iti Medical Certifier Name Title
Richard McKeever M_D_
Address
102 Rare Track Road, Ticonderoga, NY 12883
Death Certificate Filed Town of District NumberRegister Number
City, Town or Village Ticonderoga 1 '64 1 8
['Burial Date Cemetery or Crematory
['Entombment Pine View Crematory
Address
F,j3Cremation Queensbury, New York
Date Place Removed
Z Removal and/or Held
2❑and/or Address�
Hold
O Date Point of
C Transportation Shipment
G by Common Destination
VI 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
IN Name of Funeral Firm Making Disposition or to Whom
• Remains are Shipped, If Other than Above
• Address
w
Permission is hereby granted to dispose of the human remain described above as indicated.giiii Date Issued 03/2 7/201 4 Registrar of Vital Statistics -) (/r) (' t- '-__,2.)
(signature)
gl 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:
Z0,La Date of Disposition Z � Place of Disposition f? ii,t. (.414 •J a Ai 15
2 (address)
la
to
CC (section) i''& // 'num/be,,r) { (grave number)
• Name of Sexto or 'ers harge of Premises �`�' /� -i
Z I- /1 (please print)
Signatur:� S i /Pi Title l- i `oe A/`
c
(over)
DOH-1555 (02/2004)