Walsh, Fred -ti
NEW YORK STATE DEPARTMENT OF HEALTH t li Z.ic, I
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Erpd D. Walsh Male
Date of Death Age If Veteran of U.S. Armed Forces,
05/13/2013 88 yrs. War or Dates 1 942-1 946
j Place of Death Town of Hospital, Institution or
WCity, Town or Village Ticonderoga Street Address Moses-Ludington Hospital
0 Manner of Death m Natural Cause ❑Accident ❑Homicide ❑Suicide ri❑Undetermined ❑Pending
Ili Circumstances Investigation
tu Medical Certifier Name Title
G
Address
Death Certificate Filed Town of District Number Register Number
City, Town or Village Ticonderoga 1 564
❑Burial Date Cemetery or Crematory
['Entombment Pine View Crematory
g:iAddress
®Cremation Queensbury, New York
Date Place Removed
❑Removal and/or Held
and/or Address
I= Hold
C3
0 Date Point of
>Z 0 Li Transportation Shipment
Gi by Common Destination
Carrier
Disinterment Date Cemetery Address
n LiQ Reintermerit Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M.13. Clark, Inc. 01 075
Address
2310 Saranac Ave. , Lake Placid, New York 12946
ilil Name of Funeral Firm Making Disposition or to Whom •
Remains are Shipped, If Other than Above
Address
LEI
97 Permission is hereby granted to dispose of the human remain escribed boy s indicated.
Date Issued 0 5/1 4/201 3 Registrar of Vital Statistics
(sig re)
District Number 1 564 Place Town of Ticonder ga
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2
t Date of Disposition 6-if(3 Place of Disposition ,,�tVt4.) ( and o t m-
(address)
Lu
c
C (section) /blot number) ci,v414.
(grave number)
Name of Sexton or Pers n in Charge f Premises /�
(pleas pant)
Signature 7 Title
C .,AIRTO)t
(over)
DOH-1555 (02/2004)