Sammis Jr, Harold NEW YORK STATE DEPARTMENT OF HEALTH /5 "/
Vital Records Section Burial - Transit Permit
° Name First Middle Last Sex
Harold Kent Sammis, Jr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
03/19/2013 91 _rrs. War or Dates W.W. II
I-: Place of Death Town of Hospital, Institution or
Z.1 City, Town or Village Elizabethtown Street Address Elizabethtown Community Hosp.
a Manner of Death var7iNatural Cause 0 Accident 0 Homicide 0 Suicide ❑Undetermined ri Pending
ILE Circumstances Investigation
tu Medical Certifier Name Title
44
Yoh nemurn M.D.
Address
66 Park Street, Elizabethtown, NY 12932
Death Certificate Filed Town of District Number Register Number
City, Town or Village Elizabethtown 13 Sk 25
>;><OBurial Date Cemetery or Crematory
QEntombment 3/21 /201 3 Pine View Crematory
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Address ,/
' (4Cremation Queensbury, New York 1� '67�
Date Place Removed
Z a
Removal and/or Held
2and/or Address
t
Hold
0 Date Point of
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Q Transportation Shipment
3 by Common Destination
Carrier
iliiQ Disinterment Date Cemetery Address
`s Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Wilcox & Regan funeral home 01 821
iiN Address
11 Algonkin St. , Ticonderoga, NY 12883
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
CC
III
Permission is hereby granted to dispose of the human emains described above as indicated.
aii Date Issued 3/20/201 3 Registrar of Vital Statistics
(signature)
District Number t 5s- Place ,cam r za b_ ,�j iz r "_"
'' I certify that the remains of the decedent identified above'` wereJ disposed of in accordance with this permit on:
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I Date of Disposition S-22--I. Place of Disposition P I N G via,...)a,,,.) C(Z2,'n VOZ J
2 (address)
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to
CC (section) , L t number) (grave number)
Name of Sexto 'or ers . Charge of Premises ��0 Gk �
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Signature r�jv► Title C.tt ir✓t/4'la4:- 4 i .
(over)
DOH-1555 (02/2004)