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Nutt, Benjamin NEW YORK STATE DEPARTMENT OF HEALTH `3 I Vital Records Section Burial - Transit Permit Name First Middle Last Sex Benjamin Woolsey Nutt Male Date of Death Age If Veteran of U.S. Armed Forces, 07/29/2013 61 yrs. War or Dates No #- Place of Death Hospital, Institution or Town of utZ City, Town or Village Ticonderoga Street Address 83 Park Avenue ilk Manner of Death©Natural Cause ❑Accident ❑Homicide ❑Suicide ri❑Undetermined ❑Pending !tt Circumstances Investigation tu▪ Medical Certifier Name Title O Glen Chapman M.D. Address P.O. Box 29, Ticonderoga, New York 12883 Death Certificate Filed Town of District Number Register Number City, Town or Village Ticonderoga 1 564 ` 1 no El Burial Date Cemetery or Crematory 07/30/2013 Pine View Crematory ❑Entombment Address iiiii®Cremation Queensbury, New York Date Place Removed Z Removal and/or Held 0❑and/or i wiii Hold Address tl O Date Point of EL ❑Transportation Shipment a by Common Destination Carrier ❑Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Wilcox & Regan funeral home . 01 821 Mi Address 11 Algonkin St. , Ticonderoga, New York 12883 • RO Name of Funeral Firm Making Disposition or to Whom 14. Remains are Shipped, If Other than Above • Address Z l li Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 07/30/2013 Registrar of Vital Statistics /n • aLte....,L41.4.4......) (signature) Mii 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: Z ill Date of Disposition 1_I vt3 Place of Disposition 20 ...,t C r toikt 2 (address) W LO CC (section) (lot number (grave number) Name of Sexton or Pers• in Charge Premises ..)i �" e"'?t4 2I (please print) Signature /,.1 Title C1166 IL 1 (over) DOH-1555 (02/2004)