Dechame, Stephen NEW YORK STATE DEPARTMENT OF HEALTH x +' I`�!
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Stephen Pe l 1 fer_h,ame Male
Date of Death Age If Veteran of U.S. Armed Forces,
October 23, 2013 65 yrs War or Dates No
} Place of Death Town of Hospital, Institution or
Z City, Town or Village Ticonderoga Street Address 1 65 Fort Ti Road
W Manner of Death❑Natural Cause ❑Accident 0 Homicide El Suicide Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
0 C. Francis Varga M.D.
Address
P.O. Box 768, Take Placid, New York 1294,6
Death Certificate Filed Town of District Number Register Number
;i. City, Town or Village Ti rrndPrnga 1 564
❑Burial Date Cemetery or Crematory
10/25/2013 Pine View Crematory
❑Entombment Address
®Cremation Queensbury, New York
Date Place Removed
Removal and/or Held
p❑
p and/or Address
Hold
CA
0 Date Point of
EL
❑Transportation Shipment
C 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, New York 12883
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Cr
LU
Permission is hereby granted to dispose of the human re ai s descri • ab , - as indicated.
Date Issued 1 0/25/201 3 Registrar of Vital Statistics ' , .6 , •
ature)
District Number 1 564 Place Town of Ticonde oga
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z _1J
I Date of Disposition io j2$113 Place of Disposition � 4%4 �.Y,,,e. .,,,
(address)
Ili
C
C (section) (lot number) r (grave number)
CC
Name of Sexton or Person jn Charge of remises /14. L
/� r (phase p t �print)
Signature W. ! Title
(over)
DOH-1555 (02/2004)