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Frenya, Arkley NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex Arkley Dennis Frenya Male Date of Death Age If Veteran of U.S. Armed Forces, December 31, 2012 81 War or Dates Place of Death Hospital, Institution or City, Town or Village Glens Falls Street Address Glens Falls Hospital ` Manner of Death❑ Natural Cause El Accident ❑ Homicide 0 Suicide ❑ Undetermined ❑ Pending y Circumstances Investigation Medical Certifier Name Title 0. Paul F. Bachman, Address 3767 Main Street Warrensburg, NY 12885 Death Certificate Filed District Number Register Number Ci Town or Village Glens Falls J 60/ l p .4❑Burial Date Cemetery or Crematory January 3, 2013 Pine View Crematory ❑Entombment Address ®Cremation Quaker Road Queensbury,NY 12804 Date Place Removed ❑ Removal and/or Held and/or Address Hold Date Point of ❑Transportation Shipment by Common Destination Carrier ❑ Disinterment Date Cemetery Address ❑ Reinterment Date Cemetery Address Permit Issued to Registration Number <" Name of Funeral Home M. B. Kilmer Funeral Home 01079 Address 82 Broadway, Fort Edward NY 12828 i Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Address in Permission is hereby granted to dispose of the human remains descri � ` i ' ted. Registrar of Vital Statistics 247,as Date Issued ©/��Z�!-3 � (signature) District Number 5ZO/ Place -A, N) ,x, I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: i Date of Disposition 01/03/2013 Place of Disposition Quaker Road Queensbury,NY 12804 (address) f' (section) (lot number) (grave number) Name of Sexton or Person in Charge of P emises Arid obitu (please print) 1k 4 Signature 1A-- Title C f 4 Q (over) DOH-1555 (02/2004)