Cross, John v
NEW YORK STATE DEPARTMENT OF HEALTH ®
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
John RPrnarci Cross , Male
Date of Death Age If Veteran of U.S. Armed Forces,
11 /09/201 4 67 yrs War or Dates No
H- Place of Death Town of Hospital, Institution or
WCity, Town or Village Ticonderoga Street Address 176 The Portage
t0 Manner of Death Q Natural Cause D Accident El Homicide El Suicide El Undetermined D Pending
Circumstances Investigation
W Medical Certifier Name Title
Q Peter M_ ;payers
Address
Miller Road, Crown Point, NY 1 2928
Death Certificate Filed Town of District Number Register Number
City, Town or Village Ticond,-coga 1 564 57
Burial Date Cemetery or Crematory
DEntombment 1 1 /1 2/201 4 Pine View Crematory
Address
®Cremation pueensbury, New York
Date Place Removed
Z Removal and/or Held
O❑and/Holdor
F- Address
I
O Date Point of
0" Transportation Shipment
0 by Common Destination
Carrier
Disinterment Date Cemetery Address
D Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Wilcox & Regan funeral home 01 821
iii 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
It
tkt-
1;. Permission is hereby granted to dispose of the human r i described ve dicated.
Date Issued 1 1 /1 2/201 4 Registrar of Vital Statistics (31^
(sign ture
District Number 1 564 Place Town of Ticon oga
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
pPlace ofDisposition ,„44 , Cf.....-frt........Cf.....-frt........Cf.....-frt........l� Date of Disposition Vitt/K��``i 4
(address)
LU
w
tr (section) 4 (lot numbe (grave number)
ta Name of Sexton or Person �in Charge of Premises Ili, v., Jn '
(please print)
141 Signature4 Title C►7/t%v>
(over)
DOH-1555 (02/2004)