Wilcox, Marshall NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial-- Transit Permit
Name First Middle Last Sex
Marshall J. Wilcox Male
Date of Death Age If Veteran of U.S. Armed Forces,
October 26, 1997 76 War or Dates WWII
Place of Death Hospital, Institution or
mown Minerva Street Address Box 16, Main St.,
Manner of Death�atural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Daniel Way, M.D.
Address
North Creek, N.Y. 12853
Death Certificate Filed District Number Register Number
)Q Town arm Minerva 1557 1557
Date Cemetery or Crematory
❑Burial October 28, 1997 Pine View Crematory
Address
remation Queensb , N.Y. 12804
Date Place Removed
8 ❑Removal and/or Held
•• and/or Address
Hold
>
Q Date Point of
NQ Transportation Shipment
C by Common Destination
Carrier
❑Disinterment Date Cemetery Address
D utc Cemetery Address
: U Reinterment
Permit Issued to Registration Number
Name of Funeral Home Alexander Funeral Home 00017
Address
XXX
Rt. 28, North River, N.Y. 12856
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 huma/rema" s describe above as indicated.
DateIssued Oct.27,1997 Registrar of Vital Statistics
ture)District Number 1557 Place Minerva Town COffice, Minerva, N.Y.
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w Date of Disposition !�W Place of Disposition �f�AbE��� e!5X,619z uff('643
(address)
Uj
N
M (section) (lot um r) /� (grave number)
GName of Sexto or Person in Charge of remises U!J/9/�D /� /l
in (please print) C
W Signature Title
DOH-1555 (10/89) p. 1 of 2 VS-61