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Harris, Daniel ifi; Ay NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit iig Name First Middle Last Sex Daniel J. Harris Male Date of Death Age If Veteran of U.S. Armed Forces, 3/12/2013 58 yrs. War or Dates No 14 Place of Death town of Hospital, Institution or City, Town or Village Ticonderoga Street Address Moses-Ludington Hospital Manner of Death©Natural Cause ❑Accident ❑Homicide ❑Suicide El Undetermined ❑Pending IW Circumstances Investigation ill Medical Certifier Name Title Michael Sikirica Medical Examiner Address 50 Broad Street, Waterford, NY 12188 . Death Certificate Filed Town of District Number Register Number City, Town or Village Ticonderoga 1 564 20 ❑Burial Date Cemetery or Crematory ['Entombmente 013 Pine View Crematory Addrdressss Cremation Queensbury, New York Date Place Removed Z Removal and/or Held 2�and/or F* Address t Hold O Date Point of Transportation Shipment G 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 >; Address 11 Algonkin St. , Ticonderoga, NY 12883 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Address it Illy CL ` Permission is hereby granted to dispose of the human re describ b ve i dicated. iigi Date Issued -3/1 5/�0 t 3 Registrar of Vital Statistics t . (sign tur District Number 1 564 Place Town of Ticon roga I I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: 111 Date of Disposition 3.-2.? -13 Place of Disposition A ma 0.1= '1/4/- y/ 2 (address) LEE w (section) (lot number) (grave number) O ci Name of Sexto ,o son in Charge of Premises sC.-. Rd cd/,4 i (please prinifr' t) Signature Title A . (<- A (over) DOH-1555 (02/2004)