Porter, Douglas NEW YORK STATE DEPARTMENT OF HEALTH / -, )LA
Vital Records Section co s Burial - Transit Permit
t u
Name First Middle Last Sex
Douglas Lynn Porter Male
U. Date of Death Age If Veteran of U.S. Armed Forces,
03/07/2013 61 yrs. War or Dates No
Place of Death Town of Hospital, Institution or
2 City, Town or Village Ticonderoga Street Address Moses-Ludington Hospital
G1f Manner of Death u Natural Cause Accident Homicide Suicide Undetermined Pending
tt� Circumstances Investigation
tu Medical Certifier Name Title
0: C. Francis Varga M.D.
Address
2 Father Joques Place, Ticonderoga, NY 12883
Death Certificate Filed Town of District Number Register Number
City, Town or Village Ticonderoga 1 564 1 8
❑Burial Date Cemetery or Crematory
i QEntombmenf 03/1 2/201 3 Pine View Crematory
Address
: ®Cremation Queensbury, New York
Date Place Removed
Z❑Removal and/or Held
and/or Address
a Hold
07
O Date Point of
CU El O. Transportation Shipment
Li by Common Destination
Carrier
0Disinterment Date Cemetery Address
i;diQ Reinterment Date Cemetery Address
Permit Issued to Registration Number
Oi 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
Remains are Shipped, If Other than Above
Address
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!::L,::,;i.:,.1 Permission is hereby granted to dispose of the human rem 'n escribed a ve as i dicated.
Eli Date Issued 3/1 0/201 3 Registrar of Vital Statistics , lr
(sig at re)
District Number 1 564 Place Town of Tico eroga
i I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I
I Date of Disposition,]-/9 3� Place of Disposition p<✓f� l�i ems•/ (-I
1 A ..
(address)
tii
CA
tr (section) �✓�' 5# �number) (grave number)
ci O Name of Sexton erso in C of Premises � !, `0 t. jitvt S
3 7(please print)
Signature `0 d Title 6 �" 'MIL- 4
(over)
DOH-1555 (02/2004)