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Frederickson, Walter H. q61 NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Walter H. Frederickson Male Date of Death Age If Veteran of U.S.Armed Forces, 12/23/2019 89 Years War or Dates 1951-1953 Place of Death Hospital,Institution or W City,Town or Village Glens Falls Street Address The Pines At Glens Falls Center For Nursing&Rehabilitation p Manner of Death © Natural Cause Accident Homicide Suicide Undetermined Pending W Circumstances Investigation U W Medical Certifier Name Title Gwendolyn Morris-Dickinson PA Address 170 Warren St,Glens Falls, New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Glens Falls 5601 548 Burial Date Cemetery,Crematory or Facility Name 12/24/2019 Pine View Crematory Entombment Address MCremation Queensbury Town, New York Donation z Removal Date Place Removed and/or and/or Held ~ Hold Address N O �. Date Point of N Transportation Shipment p by Common Carrier Destination El Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Brewer Funeral Home Inc 00211 Address 24 Church Street PO Box 500, Lake Luzerne, New York 12846 Name of Funeral Firm Making Disposition or to Whom I— Remains are Shipped,If Other than Above 2 Address Q W d Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 12/24/2019 Registrar of Vital Statistics P&ErtAnd'aNCUrtis(ElafrcrrdlyS9W (signature) District Number 5601 Place Glens Falls, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: H W Date of Disposition 12174 Ili Place of Disposition Uj (address) W N (section) (lot number) (grave number) M 4 ` a Name of Sexton or Person in Charge of Premises t' /p!ase print) Z LU Signature Title DOH-1555(o7/18)p 1 of 2 Public Health Law Sec. 4145(2bl " ' w 13 Receipt Human remains of delivered on , 20 T View Cemetery Representing the furral horiie named on burial permit fficial Funeral Directors Reg.or License#