McCoy, Donald NEW YORK STATE DEPARTMENT OF HEALTH y
Vital Records Section Burial - Transit Permit
iiiiR Name First Middle Last Sex
Donald Franr i s Male
. A
Date of Death Age If Veteran of U.Srmed orces,
11 /13/2013 87 yrs. War or Dates W.W.II
Ja Place of Death Town of Hospital, Institution or Heritage Commons
ZCity, Town or Village Ticonderoga Street Address Residential Healthcare
W Manner of Death❑X Natural Cause 0 Accident ❑Homicide ❑Suicide 0 Undetermined ❑Pending
Circumstances Investigation
0
iii Medical Certifier Name Title
J. Gabler R_P_A_ - C
RiEiii Address
1019 Wicker Street, Ticonderoga, NY 1288
in Death Certificate Filed Town of District Number Register Number
City, Town or Village Ticonderoga 1 564
❑Burial Date Cemetery or Crematory
11 /15/2013 Pine View Crematory
!::Ei Entombment Address
cremation Queensbury, New York
Date Place Removed
Z ni Removal and/or Held
9 i—land/or Address F
Hold
in
0 Date Point of
tL D Transportation Shipment
C3 by Common Destination
in Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Wilcox & Regan Funeral Home 01 821
iiiiiiiiii Address
nii 11 Algonkin St. , Ticonderoga, New York 12883
ikiiIii Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
itti
ill
9` Permission is hereby granted to dispose of the human rem ' s describ d ab•ve as indicated.
Date Issued 1 1 /1 5/201 3 Registrar of Vital Statistics i it
i !,o w^•
i
ature)
gl District Number 1 564 Place Town of Ticonderoga
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
P (1IIII) DispositionQuU
ita Date of Disposition Place of try C�w&S�
(address)
Ili
U)
iX (section) _ , (lot nuner) (grave number)
fa Name of Sexton or Person in C arge of Premises AA/Air 19
ii (please print)
Signature Title aU P dh
(over)
DOH-1555 (02/2004)