Wilcox, Arthur NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Arthur D. Wilcox male
Date of Death Age If Veteran of U.S. Armed Forces,
March 4, 1999 95 War or Dates
Place of Death Hospital, Institution or
A34,x-R=x:mVillage Cambridge Street Address Skilled Nursing Facility
Manner of Death®Natural Cause ❑Accident ❑Homicide ❑Suicide Undetermined ❑Pending
Circumstances Investigation
Medical Certifier Name Title
Matthew C. Pender MD
Address
1 Myrtle Ave. , Cambridge, NY 12816
Death Certificate Filed District Number Register Number
txTu�e =Village Cambrid e24
Date Cemetery or Crematory
❑burial March 5, 1999 Pine View Cremator
Address
Cremation Queensbury, NY
FDate Place Removed
Z ❑Removal and/or Held
.— and/or Address
Hold
Q Date Point of
4-❑Transportation Shipment
by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Renterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Flynn Bros. , Inc. 00665
Address
80 Main St. , Greenwich, NY 12834
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 3/5/9 9 Registrar of Vital Statistics
(signature)
District Number
Place t /
I certify that the remains of the decedent identified aboveVwere dispose of in accordance with this permit on:
DW. ate of Disposition Place of Disposition �/Y.��.�l� 411 CF
W (address)
LU
N
t>E (section) (lot numbed j (grave number)
GName of Sexto or Person in Charge of Premises
g (please print) /
Signature & Title
71
DOH-1555 (10/89) p. 1 of 2 VS-61