Cooper, Harry R 10F: 41-
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NEW YORK STATE DEPARTMENT OF HEALTH - Permit
Bureau of Vital Records Burial Transit P@
Name First Middle Last Sex
Harry R Cooper Male
Date of Death Age If Veteran of U.S.Armed Forces,
09/10/2022 88 Years War or Dates 1951-1955
F. Place of Death Hospital,Institution or
Z City,Town or Village Ticonderoga Town Street Address Elderwood at Ticonderoga
W
p Manner of Death ci Natural Cause Accident El Homicide Suicide ❑Undetermined ❑Pending
W Circumstances Investigation
WMedical Certifier Name Title
0 Kristin Mack DO
Address
1019 Wicker St,Ticonderoga Town,New York 12883
Death Certificate Filed Town Of Ticonderoga District Number Register Number
City,sown or Village 1564 42
Burial Date Cemetery,Crematory or Facility Name
09/13/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,Warren,New York
nDonation
Z Removal Date Place Removed
❑and/or and/or Held
F Hold Address
N
0
d Date Point of
(Q❑Transportation
p by Common Shipment
Carrier Destination
!DisintermentDate Cemetery Address
Date Cemetery Address
Reinterment
Permit Issued to Registration Number
Name of Funeral Home Edward L Kelly Funeral Home 00519
Address
PO Box 548,Schroon Lake,New York 12870
Name of Funeral Firm Making Disposition or to Whom
f`. Remains are Shipped,If Other than Above
M Address
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Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 09/12/2022 Registrar of Vital Statistics .?ortt) 1117lompsoni2=ketronfi ,5 rted3
(signature!
District Number 1564 Place Town Of Ticonderoga
I certify that the remains of the decedent identified above were disposed of in accordance with this permittoon: I
Z▪ Date of Disposition 9 113 11j1 Place of Disposition 't ' c,l� 6—„,
W (address)
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CCCC (section) (lot number) < v14, (grave number)
0 Name of Sexton or Person in of Premises -e\ at
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Signature
DOH 1555(o7(18)p t of 2
PUBLIC HEALTH LAW
§ 4145. Deaths; burial and removal permits; disposition of remains. 1. No person in charge of any premises on which
interments, cremations or other disposition of the body of a deceased person are made shall inter or permit the
interment or other disposition of any body unless it is accompanied by a burial,cremation or transit permit,as provided
in this article.
2.(a)The funeral director or undertaker shall deliver the burial permit to the person in charge of the place of burial or
other disposition before interring or otherwise disposing of the body or shall attach the removal or transit permit to the
box containing the body,when shipped by any transportation company,which permit shall accompany the remains to its
destination, where, if within this state, it shall be delivered to the person in charge of the place of burial or other
disposition.
(b) Any person or other entity owning,operating,managing,or designated to receive the body of a deceased person at a
place of burial, cremation, or other final disposition in this state, who receives the body of a deceased person, shall
provide a receipt for the body to the funeral director, undertaker or registered resident who delivered such body. Each
receipt shall(i) be endorsed by both such person and the funeral director, undertaker or registered resident, (ii) indicate
the date the body was delivered, (iii) include the name of the funeral director, undertaker or registered resident
delivering the body and the registration number of such funeral director,undertaker or registered resident, (iv) include
the name of the registered funeral firm the funeral director, undertaker or registered resident represents,(v)include the
name of the deceased person as it appears on the burial, cremation,or transit permit, and (vi) include the name of the
owner,operator,manager,or person in charge of the place of burial,cremation, or other final disposition who received
the body of the deceased person.A copy of such receipt shalt be retained by the owner,operator, manager,or person in
charge of the place of burial,cremation, or other final disposition for a period of not less than four years, and shall be
made available for inspection by the division of cemeteries during normal business hours.The original copy of every such
receipt shall be retained by the licensed funeral firm for a period of not less than four years pursuant to the rules and
regulations of the department governing the maintenance of records.
3.The person in charge of the place of burial or other disposition shall endorse upon the permit,the date of interment,
or cremation or other disposition over his signature, and shall return all permits so endorsed to the registrar of his
district within seven days after the date of interment,cremation or other disposition.
4. When burying or otherwise disposing of the body of a deceased person in a cemetery or burial place having no
person in charge,the funeral director or undertaker shalt (a)sign the burial or removal permit,giving the date of burial;
(b) write across the face of the permit the words"No person in charge;"and (c) file the burial or removal permit within
three days with the registrar of the district in which the cemetery is located.
5.The person in charge of the place of burial,cremation,or other disposition shall keep a record of all bodies interred or
otherwise disposed of on the premises under his charge,in each case stating the name of each deceased person,place of
death, date of burial or disposal, and name and address of the funeral director or undertaker,which record shalt at all
time be open to official inspection.
DOH 1555(07/18)p 2 of 2
U is :,e '
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#