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Frasier, Richard Al ,..NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit 'r . Name First Middle Last Sex Richard Do le Frasier Male Date of Death Age If Veteran of U.S. Armed Forces, May 26, 2016 78 War or Dates n/a s Place of Death Hospital, Institution or City, Town or Village Glens Falls,NY Street Address Glens Falls Hospital ' Manner of Death C Natural Cause n Accident 0 Homicide n Suicide n Undetermined ri Pending Circumstances Investigation MedicalMedpkCertifier Name . Title .0., _ II .\ c.� \ r• CD S - Idress ,, Death Certificate Filed ' District Number Register M City, Town or Village Glens Falls, NY 5601 ©Burial Date Cemetery or Crematory ❑Entombment May 31,_2016 Pine View Cemetery Address ❑Cremation Quaker Road Queensbury, Queensbury,NY 12804 Date Place Removed ZZ n Removal and/or Held and/or Address H Hold V) dDate Point of y Li Transportation Shipment p by Common Destination Carrier n Disinterment Date Cemetery Address Li Reinterment Date Cemetery Address >%' Permit Issued to Registration Number ;� Name of Funeral Home Sin.leton Sullivan Potter Funeral Home 01596 • Address , 407 Ba Road, I ueensbur , NY 12804 Name of Funeral Firm Making Disposition or to Whom t Remains are Shipped, If Other than Above f4 Address ePermission is hereby granted to dispose of the human remains described above as indicated. Date Issued 5 1 Z '7 /(it; Registrar of Vital Statistics (,�J c j, (., (signature) y District Number 5 6 c,i Place c, ( „ S FLA ( \S h%i, I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z Lu Date of Disposition 5/31 /201 (,Place of Disposition Pine ViPW CPmPtPry, Queensbury,NY (address) LU Wah—Ta—Wah 121 , Sec 33 13 pCe (section) (lot number) (grave number) Name of Se n or Person in Charge of Premises Connie L. Goedert Z (please print) w Signature/ Kitt/ .e c e. — Title Cemetery Superintendent (over) DOH-1555(02/2004)