Frocklage, Anita NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
};: Name First Middle Last Sex
Anita Frocklage Female
r' Date of Death Age If Veteran of U.S. Armed Forces,
May 5, 2015 85 War or Dates
' Place of Death 4 Hospital, Institution or
City, Town or Village r l r y Street Address Washington Center
Manner of Death g Natural Cause Accident I I Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Pam Casey
'rr�;� Address
35 Gilbert Street,Cambridge,NY 12816
.j;:; Death Certificate Filed District Number Register Number
City, Town or Village Argyle S}50 S
i;y ?So
❑x Burial Date Cemetery or Crematory
May 6, 2015 Pine View Cemetery
❑Entombment Address
❑Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
ZZ I I Removal and/or Held
and/or Address
F_ Hold
O Date Point of
N Transportation Shipment
`p by Common Destination
Carrier
Disinterment Date Cemetery Address
n Reinterment Date Cemetery Address
✓A Permit Issued to Registration Number
' Name of Funeral Home Regan Denny Stafford Funeral Home 01443
''•: Address
ii:?:i 53 Quaker Road, Queensbury,NY 12804
}r?? Name of Funeral Firm Making Disposition or to Whom
•,1Remains are Shipped, If Other than Above
Address
fr,., Permission is hereby granted to dispose of the human re ains described above as indicated.
;�. Date Issued S,$'' iS Registrar of Vital Statistics 9 \-1111 L/ CAA‘,.,,,
;' 1 _I (signature)
575J
'$; District Number rip Place Argyle
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 5/6/2 01 5 Place of Disposition Pine View C.emet er Qu PPn s hn ry, NY
W address)
cn Seneca 26-B 1
0 (section) (lot number) (grave number)
QName of Se n or Person in Charge of Premises Connie L. Goedert
Z (please print)
w Signature �Alt� Title Cemetery Superintendent
(over)
DOH-1555(02/2004)