Carr, Donald // (930
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Donald Rryan Carr Male
Date of Death Age If Veteran of U.S. Armed Forces,
10/04/2014 85 yrs_ War or Dates 1948-1987
I- Place of Death Hospital, Institution or
Town of Heritage Commons
WCity, Town or Village Ticonderoga Street Address Res i dent i al HPa 1 thcare
• Manner of Death❑X Natural Cause ElAccident ElHomicide ❑Suicide ❑Undetermined Pending
iLlCircumstances Investigation
W Medical Certifier Name Title
Q Kathleen Huestis M.D.
Address
1019 Wicker Street, Ticonderoga, NY 12883
Death Certificate Filed Town of District Number Register Number
City, Town or Village Ti r-nndPrnga 1 564 50
❑Burial Date Cemetery or Crematory
10/07/2014 PinP View Crematory
❑Entombment Address
®Cremation Queensbury, New York
Date Place Removed
Z n Removal and/or Held
P and/or
� Address
in
Hold
0 Date Point of
❑Transportation Shipment
O by Common . Destination
Carrier
Q Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
I 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
1, Remains are Shipped, If Other than Above
2 Address
IX
Ili
'. Permission is hereby granted to dispose of the human rem ins described above as indicated.
Date Issued 1 0/7/201 4 Registrar of Vital Statistics / i n , 4.1.12_,�.>
(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:
WDate of Disposition 10/ iy Place of Disposition ,►ttil~./ Co.„4-G,
2 (address)
Ui
VI
CC (section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises d "'-,.$1-01—tP- Str,`
Z � (please print)
lL• Signature t'&j Title commit
(over)
DOH-1555 (02/2004)