Wagg, Frederick I IS3
NEW YORK STATE DEPARTMENT OF HEALTH ,
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Frederick G. Wagg Male
Date of Death Age If Veteran of U.S.Armed Forces,
October 10,2006 74 War or Dates
H Place of Death City of Glens Falls Hospital, Institution or Glens Falls Hospital
Z City,Town or Village Street Address
W Manner of Death ElNatural Cause ElAccident ElHomicide ElSuicide IDUndetermined ElPending
Circumstances Investigation
U Medical Certifier Name Title
W 0 Susan Blood MD
Address
453 Dixon Rd.,Queensbury,NY 12804
Death Certificate Filed District Number Register 1717
City,Town or Village Glens Falls 5601 /�
El Burial Date Cemetery or Crematory
10/11/2006 Pine View Crematory
❑ Entombment Address
® Cremation Queensbury,NY
Date Place Removed
z ❑ Removal and/or Held
0 and/or Address
p Hold
N Date Point of
N ❑ Transportation Shipment
by Common Destination
G Carrier
Date Cemetery Address
❑ Disinterment
Date Cemetery Address
❑ Reinterment
Permit Issued to Registration Number
Name of Funeral Home Alexander-Baker Funeral Home 00036
Address
3809 Main Street,Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
1„. Remains are Shipped, If Other than Above
- Address
It
aPermission is hereby granted to dispose of the human remains descri�e�,a/bov 7dicDate Issued 10-11-06 Registrar of Vital Statistics �G �a� Jrz
(signature)
District Number 5601 Place Glens Falls,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I!—
Z Date of Disposition i ,/i A/61. Place of Disposition 19�n t vtt�, C.r s T o f0,,v t
I (address)
W
V) (section) ((lot number) (grave number)
SName of Sexton or Person in Charge of Premises C� s Jc'n r.6f
/; r (please print)
W Signature 4'Lw Title Cam. 1-or
DOH-1555(02/2004) (over)