Martin, Ernest f L
NEW YORK STATE DEPARTMENT OF HEALTH q0 I
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
iiia
Ernest W. Martin Male
gi':i Date of Death Age If Veteran of U.S. Armed Forces,
12/26/2013 66 yrs. War or Dates 1964-1968
. Place of Death Town of Hospital, Institution or
5 City, Town or Village mi con rieroaa Street Address Moses-Ludington Hospital
Ct Manner of Death 0 Natural Cause�Accident El Homicide 0 Suicide ri Undetermined Pending
t Circumstances Investigation
tu Medical Certifier Name Title
Glen Chapman M.D.
Address
P.O. Box 29, Ticor.dProga NY
Death Certificate Filed Town of District Number Regist ber
City, Town or Village Ticonderoga 1 564
iiiiiii CIBurial Date Cemetery or Crematory
12/27/2013 Pine View Crematory
iii,:i Entombment Address
EICremation Queensbury, New York
Date Place Removed
Z Removal and/or Held
9❑and/or
Address�,;;
CA
Hold
0 Date Point of
iw ri Transportation Shipment
t by Common Destination
Carrier
Q Disinterment Date Cemetery Address
111,0
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
iili 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
1 . Remains are Shipped, If Other than Above
2 Address
1e
ill
Permission is hereby granted to dispose of the human rem -ns described above as indicated.
fOil Date Issued 1 2/27/201 3 Registrar of Vital Statistics _ /7) �.
(signature)
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:
la Date of Disposition I1/31 f 1-3 Place of Disposition Lit.J 0 i.._,
2 (address)
w
ta
CC (section) - nu ber) (grave number)
ri Q Name of Sexton or Person � Charge of Premises /(It
t "`"
/ (plea e print)
Signature Title
(over)
DOH-1555 (02/2004)