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Stanley, John NEW YORK STATE DEPARTMENT OF HEALTH # Sti' Vital Records Section i Burial - Transit Permit Name First Middle Last Sex John S. Stanley Male Date of Death Age If Veteran of U.S. Armed Forces, 7/06/2012 95 yrs. War or Dates W.W. II Place of Death Town of Hospital, Institution or Heritage Commons City, Town or Village Ticonderoga Street Address Residential Healthcare ILIManner of Death E9 Natural Cause El Accident ❑Homicide ❑Suicide El Undetermined ❑Pending ILICircumstances Investigation ui Medical Certifier Name Title 0 Toni Sturm M.D. Address 1019 Wicker Street, Ticonderoga, NY 12883 Death Certificate Filed Town of District Number Register Number >> City, Town or Village Ticonderoga 1 564 38 EI❑Burial Date Cemetery or Crematory 7/09/2012 Pine View Crematory :::❑Entombment Address ©Cremation Queensbury, New York Date Place Removed Z ❑Removal and/or Held and/or Address E Hold W. 0 Date Point of ❑Transportation Shipment a 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. , P.O. Box 543, Ticonderoga, NY 12883 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Address LU ` Permission is hereby granted to dispose of the human re ains described above as indicated. Date Issued 7/9/2 01 2 Registrar of Vital Statistics .142 'y 17 1 d &.-,+- (signature) IR District Number 1 564 Place Town of Ticonderoga (2 $`6 ' I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: ILI Date of Disposition 1-to- l2 Place of Disposition s u vw, Cr..d0 C1` (address) ILI CC (section) (lot numbe (gra've number) 0. ci Name of Sexton or Person in C rge of Premises (+rh1.r -4 f" *► (please print) Signature 4C. Title Ch wnr.-OQ (over) DOH-1555 (02/2004)