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Wilcox, William Joseph 1-1 3v--) NEWYORKSTATEDEPARTMENTOFHEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex William Joseph Wilcox Male Datq; f Death Age If Veteran of U.S.Armed Forces, 04CY412023 79 Years War or Dates i— Place of Death Hospital,Institution or Z City,Town or Village Fort Ann Town Street Address 183 Burquist Road,Fort Ann Town,New York 12827 WManner of Death El Natural Cause Accident El Homicide Suicide Undetermined n Pending U Circumstances Investigation C Medical Certifier Name Title Curtis Gedney MD Address 454 Glen Street,Glens Falls,New York 12801 Death Certificate Filed Town Of Fort Ann District Number Register Number ,Town or Village Cie 5754 Burial Date Cemetery,Crematory or Facility Name 04/17/2023 Pine View Crematorium Entombment Address ©Cremation Queensbury Town,New York Donation 0❑Removal Date Place Removed and/or and/or Held ~ Hold Address M 0 O. Date Point of Cl) Transportation a by Common Shipment Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home Inc 00281 Address 68 Main Street,P.O.Box 67,Hudson Falls,New York 12839 Name of Funeral Firm Making Disposition or to Whom I— Remains are Shipped,If Other than Above 2 Address Q W a. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 04/17/2023 Registrar of Vital Statistics Miranda Jferringsfaw(EfectronicaQySigned) (signature) District Number 5754 Place Town Of Fort Ann I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: ZW Date of Disposition y I$123 Place of Disposition 417...V,— ,6.,... 2 (address) UJ 2 (section) l/umber/ (grave number) ar g Name of Sexton or Person in Charge of Premises L A t.r it Z (please p intl W Signature Title re"4'194 DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home namedon burp"permit Official Funeral Directors Reg.or License# °