Venn, Frank NEW YORK STATE DEPARTMENT{fHEALTH ��&8�~��N ~ ���%�����~� �������^�
Vha| Records Seu�n �~~~~ ~~,~ Transit Permit
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D�e of-. �����--�------ ---- Age ��V���,������V'�./����������.
War orD�oo yes Wa,
Place of Death Hospital, Institution or
Chy,Town orVillage Glens Falls, NY Street Address
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o»n«r �JO 0a1uno|Couoe �-� Ancidont �-1 Hom�ido [-1 Suicido �-7 n m F-� ~
�-� �-� �-� �� �� Circumstances Investigation
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- - ----- -~~~~Death Certificate Filed District Number Register Number
-
City,Town mVillage Glens Falls, NY 5601
~� Dateor~- Bu�� 1-8-9I Ptze'\�%w Crematory
� �]C Cremation "°~="Vueeuab�y, 0Y 12884 -
��--___-____ -___-__ ���� __-___-___________
Date
x2 [l Removal and/or Held
� and/or Hold -------------........ . .......--...
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o' Date Point of
�on E]Toanxportationby Shipment
o Common Carrier ..
..........
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�l Dioimonnonu --- Cemetery-- Address
Fl Reimonnanu --- Cemetery-- Address
Permit Issued to Registration Number
Name of Funeral Firm Jams F. Singletonjnc.
01850
Address
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 hum remains describe5 above as indicated.
Date Issued 1-7-91 Registrar of Vital Statistics
District Number 5601 City of Glens Falls, NY 12801
|certify that the remains of the decedent identified above were disposed of in accordance with this pomnb on:
Date cdDisposition Place ofDispositionUj
2 (address)
LLICn
cc (section)
(lot number) (grave number)
0 Name of Sextn Charge of Premises wr ^f �^' k�~7'0rk~~/,
z (please print) '
`" Signature Th|v '
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