Henthorn, Dennis NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
•
«' Name First Middle Last Sex
Dennis Allan Henthorn Male
«= Date of Death Age If Veteran of U.S. Armed Forces,
mi
May 4, 2 018 6 7 yrs. War or Dates No
Place of Death Town of Hospital, Institution or Moses-Ludington Hospital
City, Town or Village Ticonderoga Street Address
Manner of Death 2 Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
US Circumstances Investigation
ill Medical Certifier Name Title
C. Francis Varga M.D.
Address
P.O. Box 768, Lake Placid, NY 12946
Death Certificate Filed Town of District Number Register Nuret
City, Town or Village Ticonderoga 1 564 (Q
❑Burial Date Cemetery or Crematory
lig
.❑Entombment 5/7/2018 Pine View Crematory
Address
'.®Cremation Queensbury, New York
Date Place Removed
❑Removal and/or Held
and/or Address
le Hold
fIS
Date Point of
❑Transportation Shipment
by Common Destination -
Carrier
ft
❑Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Wilcox & Regan funeral hemp 41 821
Address
s11 Algonkin St. , Ticonderoga, New York 12883
Name of Funeral Firm Making Disposition or to Whom
14 Remains are Shipped, If Other than Above
2 Address
CC
X
Permission is hereby granted to dispose of the human rema" s escribed abve 'ndicated.
Date Issued 5/7/2 018 Registrar of Vital Statistics
(sign ur)
District Number 1 564 Place Town of Ticonderoga
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
41/ Date of Disposition Sit lit Place of Disposition 7.4- 4wr-or —
2 (address)
ul
to
Ir (section) A (lot number)(.. (grave number)
Name of Sexton or Person in Charge of Premises /"^+ ^^ j`'"
(please print)
Signature Title /000'1f1
(over)
DOH-1555 (02/2004)