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Fish Jr, Floyd , NEW YORK STATE DEPARTMENT OF HEALTH . . ^2 b # 7O Vital Records Section Burial - Transit Permit Name First Middle Last Sex Floyd H. Fish, Jr. Male > Date of Death Age If Veteran of U.S. Armed Forces, 02/03/2013 80 yrs. War or Dates 1 951 -1 953 j Place of Death Town of Hospital, Institution or Heritage Commons ZCity, Town or Village Ticonderoga Street Address Residential Healthcare a Manner of Deathior71 Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending lit. Circumstances Investigation iii Medical Certifier Name Title Q Todd R. Waldorf D.O. Address • 1019 Wicker Street, Ticonderoga, NY 12883 Death Certificate Filed Town of District Number Register Number City, Town or Village Ticonderoga 1 564 1 0 ❑Burial Date Cemetery or Crematory ❑Entombment 02/05/2013 Pine View Crematory Address ©Cremation Queensbury, New York • Date Place Removed Z❑Removal and/or Held 2 and/orlo• Address ` Hold tO 0 Date Point of tEL Transportation Shipment 0 by Common Destination ni 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 14 Remains are Shipped, If Other than Above ';; Address L 1' Permission is hereby granted to dispose of the human re i described a ve -s ' dicated. Date Issued 02/0 5/201 3 Registrar of Vital Statistics . . -"0"--V -5\rN (sign District Number 1 564 Place Town of Ticon oga I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z ill Date of Disposition 2-t1)-(5 Place of Disposition 'F-IL Crt.,{pr,r... a (address) Ul Cl) CC (section) ka ot number) (grave number) Ct ci Name of Sexton or Person in Char a of Premises Sa-.,lt-k Z (ple se print) La Signature (4L Title cea h"a(L (over) DOH-1555 (02/2004)