Evans,Gary Lee NEW YORK STATE DEPARTMENT OF HEALTH ! '"'"' "" Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Frederick J Stone Male
Date of Death Age If Veteran of U.S.Armed Forces,
01/14/2020 64 Years War or Dates 81-84
Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
W Manner of Death Undetermined Pending
� � Natural Cause �Accident �Homicide �Suicide � � g
W Circumstances Investigation
U
W Medical Certifier Name Title
0 Mathew Varughese DO
Address
100 Park St,Glens Falls, New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 31
Burial Date Cemetery,Crematory or Facility Name
01/16/2020 —7Pine View Crematory
Entombment Address
x❑Cremation Queensbury Town,New York
❑Donation
ZORemoval Date Place Removed
and/or and/or Held
F-N Hold Address
O
0' Date Point of
U) Transportation p by Common Shipment
Carrier Destination
El Disinterment
Date Cemetery Address
Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D Baker Funeral Home 01130
Address
11 Lafayette St,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
�.. Remains are Shipped,If Other than Above
Address
Q
W
n' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/16/2020 Registrar of Vital Statistics A4e t..4ndrewCurt.(Elect vnwaT Syned)
(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 `
Z Date of Disposition ( I n I zo Place of Disposition r..
W (address/
2
W
U) (section) (lot number/ (grave number)
INL—
G Name of Sexton or Person in Charge off muses di'—s
Z /"" lease print
W Signature b Title
DOH-1555(o7/18)p 1 of 2
Public Health Law Sec. 4145(2b)
Receipt
i
Human remains of Y' delivered on_ p ` , 20_C
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License 1# ;