Besson, George NEW YORK STATE DEPARTMENT OF HEALTH.. \ 4 31
Vital Records Section Burial - Transi Permit
Name First ` Middle Last Sex
George Robert Besson Male
Date of Death Age; ` �. If Veteran of U.S. Armed Forces,
May 21 , 2013 '85-y'rs; War or Dates W.W. II
} Place of Death Town of Hospital, Institution or
Z City, Town or Village Ticonderoga Street Address 38 3rd. Avenue
iii
▪ Manner of Death® Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
IL/ Circumstances Investigation
ta Medical Certifier Name Title
C} Glen Chapman M.D.
Address
P.O. Box 29, Ticonderoga, NY 12883
Death Certificate Filed Town of District Number Register Number
City, Town or Village Ticonderoga 1 564 34
❑Burial Date Cemetery or Crematory
❑Entombment 05/28/2013 Pine View Crematory
Address
:,®Cremation Queensbu.ry, New York
Date Place Removed
Removal and/or Held
CI6and/or
�;; Address
E Hold
0 Date Point of
vi Li Transportation Shipment
Es by Common Destination
Carrier
El Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Wilcox & Regan funeral home 01 321
Address
11 Algonkin St. , Ticonderoga, NY 12883 •
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Cr
ill
IL
Permission is hereby granted to dispose of the human rema' describe ove = indicated.
Date Issued 0 5/23/201 3 Registrar of Vital Statistics - -y'Oc'`"\
(sig 6)
District Number 1 564 Place Town of Ticon eroga
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2
IILI Date of Disposition 5(w jE3 Place of Disposition - X") Cio*S f P,,,...
2 (address)
In
ilk
C (section) (lot n bekr) (grave number)
JCS Name of Sexton or Persil in Charge o Premises R?t. g
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(please prin
SignatureTitle C(t+E'MVi r1
(over)
DOH-1555 (02/2004)