Bartlett, Gillette NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
s
Name First Middle Last Sex
Gillette C. Bartlett Male
Date of Death Age If Veteran of U.S. Armed Forces,
05/20/2013 75 yrs. War or Dates 1958-1964
Place of Death Town of Hospital, Institution or
Z City, Town or Village Ticonderoga Street Address 28 Highland Street
0 Manner of Death 5 Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
LU Circumstances Investigation
at Medical Certifier Name Title
IP 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 33
❑Burial Date Cemetery or Crematory
❑Entombment 05/24/2013 Pine View Crematory
Address
illi®Cremation Queensbury, New York
Date Place Removed
Z Removal and/or Held
and/or
�;; Address
in
Hold
0 Date Point of
t
Transportation Shipment
. by Common Destination
Carrier
iii
ni❑Disinterment Date Cemetery Address
g ❑Reinterment Date Cemetery Address
i: Permit Issued to • Registration Number
Name of Funeral Home Wilcox & Regan Funeral Home 01 821
niii Address •
gil 11 Algonkin St. , Ticonderoga, NY 12883
gi Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
ir
lL
Permission is hereby granted to dispose of the human re i s descri abo - -s indicated.
ni Date Issued 0 5/23/201 3 Registrar of Vital Statistics l >4� 0.e.
(fi ture)
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
ILI Date of Disposition 5I 73!3 Place of Disposition ./1)U �stw-iCw-
(address)
ti
te
re (section) (lot numb (grave number)
ti Name of Sexton or Per on in Charge Premises �� `�"�`�
(please print)
fLi
Signature • t , -- -- Title CW014707
(over)
DOH-1555 (02/2004)