Ives, Phillip x tt77g
NEW YORK STATE DEPARTMENT OF HEALTH ` - 'r
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Phillip John Ives Male
Date of Death Age If Veteran of U.S. Armed Forces,
1 1 /1 91201 4 64 yrs_ War or Dates 1 969-1 974
w- Place of Death Town of Hospital, Institution or
Z City, Town or Village Street Address 47 Park Avenue
W Ticonderoga
p Manner of Death Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
uj Medical Certifier Name Title
In Glen Chapman M.D.
Address
P.O.. Box 2 , Ticonderoga, NY 1 2383
Death Certificate Filed Town of District Number Register Number
City, Town or Village Ti rnndPrnga 1 564 61
0Burial Date Cemetery or Crematory
]Entombment 11 /24/201 4 Pine View Crematory
Address
®Cremation _ Queensbury, New York
Date Place Removed
Removal and/or Held
,C): ❑and/or
Address
Hold
0 Date Point of
Q Transportation Shipment
G by Common Destination
Carrier
Q 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. , Ticonderoga, NY 12883
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
CC
IIUJ
` Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 1 1 /21 /2 01 4 Registrar of Vital Statistics `,�tiL ) • G�,Q,[�,v
J°' (signature)
District Number 1 564 Place Town of Ticonderoga
F-
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
V crt�.,.47(!
t Date of Disposition IJ/Mitt Place of Disposition , ,,�,� Ciu-,
2 (address)
U)
C (section) i (12t number) (grave number)
C
p Name of Sexton or Person in Charge of Premises ��¢,IA4,tr
z / ( lease print)
Ui
Signature !i'l,,i .4 Title C1bf iftif FK,
(over)
DOH-1 555 (02/2004)