Francett, John '76
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section A
k Name First Middle 1 Last Sex
John W Francett : Male
itit Date of Death - Age If Veteran of U.S. Armed Forces,
02/01/2006 80 years War or Dates 1943-46
Place of Death Hospital, Institution or
City, Town cXXXX4XXXX City Of Glens Falls Street Address Glens Falls Hospital
Manner of Death aNratural Cause ❑Accident ❑Homicide ❑Suicide ri❑Undetermined ri❑Pending
Circumstances Investigation
lij Medical Certifier Name Title
Ageel A. Gi Iani M D
Address
102 Park Street Glens Falls, N Y 12801
iiili Death Certificate Filed District Number Register Number
City, Town d(XJA bXXXX City Of Glens Falls 5801 50
Date Cemetery or Crematory
❑Burial 02/02/2006 Pine View Crematorium
Address
}`4Cremation Queensbury, NY 12804
Date Place Removed
0❑Removal and/or Held
. and/or Address
aHold
2. Date Point of
N❑Transportation Shipment
a by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
>' Permit Issued to Registration Number
Name of Funeral Home Maynard D. Baker Funeral Home 01194
• Address
giiii 11 Lafayette Street Queensbury, N Y 12804
iiiiiiii Name of Funeral Firm Making Disposition or to Whom
'" Remains are Shipped, If Other than Above
Address
IM
VA
CC
iiiii Permission is hereby granted to dispose of the human remains described above_as i cated.
iiiii 02/02/2006 /
Date Issued Registrar of Vital Statistics ��,��./ Gti
(signature) /__//
District Number c5-6C/ Place lc/ � 16/ /1)7
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
H
6 Date of Disposition -a,-3--L (4, Place of Disposition P/Xi t tF(1i.) C Lt t-M/4ko ,':. 1 t7
(address)
iLl
N
CC (section) pp�� (lot number) (grave number)
0 Name of Sexton or Person in Charge of Premises -i r? Vi Lam'f f)q-J
z - (please print)
W Signature _.,r� / Title f�h ei 2j4- (.�i
I r
(over)
DOH-1555 (9/98)