St. Andrews, Jimmy NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Permit
Name First Middle Last Sex
Jimmy Joe St. Andrews Male
Date of Death Age If Veteran of U.S. Armed Forces,
gV 7/1 6/201 2 4 5 yrs. War or Dates No
t Place of Death Town of Hospital, Institution or
City, Town or Village Ticonderoga Street Address Mt. Hope Cemetery Property
0 Manner of Death L. Natural Cause Accident Homicide ®Suicide Undetermined Pending
W. Circumstances Investigation
'u Medical Certifier Name Title
P. C. Francis Varga M.D.
Address
P.O. Box 768, Lake Placid, NY 12946
Death Certificate Filed Town of District Number Register Number
City, Town or Village Ticonderoga 1 564
❑Burial Date Cemetery or Crematory
7/18/2012 Pine View Crematory
❑Entombment Address
iMi ®Cremation Queensbury, New York
Date Place Removed
Z Removal and/or Held
0❑and/or
i Address
to
Hold
0 Date Point of
itL
❑Transportation Shipment
L3 by Common Destination
Carrier
Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Wilcox & Regan funeral hone 01 821
in Address
iiNi 11 .Algonkin St. , Ticonderoga, NY 12883
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
w
Permission is hereby granted to dispose of the human rem - escrib ab as indicated.
giiii Date Issued 7/1 8/201 2 Registrar of Vital Statistics C� / ��
' q
(signature)r� �
NEE District Number 1 564 Place Town of Ticon 3roga
>.::: I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2 '1
ILI Date of Disposition 1-t b- 12 Place of Disposition 'i 2 r�wUkt) Cr,r„(73r 11A-
(address)
111
LC (section) /iI
r.)'ft40U.- (lot number) (grave number)
Name of Sexton or Person in Charge f Premises �'C I �'f'W).
(please print)
44:: Signature �� Title Cmowl-611,
(over)
DOH-1555 (02/2004)