Wilcox Sr, Jackie SS Z
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last I Sex
Jackie A. Wilcox,Sr. I Male
Date of Death Age If Veteran of U.S. Armed Forces,
September 15,2013 80 War or Dates
Place of Death Hospital, Institution or
Z City, Town or Village Jay Street Address 853 Bartlett Road
p Manner of Death {x Natural Cause I I Accident Homicide Suicide Undetermined Pending
W Circumstances Investigation
W Medical Certifier Name Title
O Francis W.Whitelaw Coroner
Address
60 Maple Lane,Bloomingdale,NY 12913
Death Certificate Filed G., District Number Register Number
City, Town or Village VcALI 15514 i-f
❑Burial Date Cemetery or Crematory
September 17,2013 Pine View Crematory
❑Entombment Address
0 Cremation 21 Quaker Rd., Queensbury,NY 12804
Date Place Removed
ZZ I I Removal and/or Held
and/or Address
1::: Hold
Cl)
O Date Point of
05 I I Transportation Shipment
a by Common Destination
Carrier
I Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M.B. Clark,Inc. 01075
Address
2310 Saranac Ave., Lake Placid,NY 12946
Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped, If Other than Above
Z Address
Ce
W
IL Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued t- 1 1 - 13 Registrar of Vitalit Statistics Ca4,LLL l \L KA-e t/ —(Ani_ a.
C.) (signiaure)
District Number 1551.E Place d�li
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
F-
W Date of Disposition l 111113 Place of Disposition to
us &y4•_ 114--
2 (address)
W
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CC (section) (lot number (grave number)
pName of Sexton or Person in Charge of Premises dr,A reir Jl @v
Z (please print)
W 71/1—
Signature _ Title C$ WYt
(over)
DOH-1555 (02/2004)