Namer, Frederick NEW YORK STATE DEPARTMENT OF HEALTH # (Dili
Vital Records Section 6, Burial - Transit Perm t
Name First Middle Last Sex
Frederick P, Namr Male
Date of Death Age If Veteran of U.S. Armed Forces„�i
08/28/2017 59 years War or Dates b
Place of Death Town of Hospital, Institution or I
City, Town or Village Ticonc�Prna Street Address 15 way nP Avenue
0 Manner of Death®Natural Cause �ccident ['Homicide 0 Suicide riUndetermined El❑Pending
Circumstances Investigation
iii Medical Certifier Name Title
JamPG Gabler RPA-C
Address
Death Certificate FiledTiconderoga Health ISEtnctjufnbec ondcroga, NYiniii Register Number
Town of
mil City, Town or Village Ti rondo xoga 1 564 1
Ei 0 Burial Date Cemetery or Crematory
08/29/2017 Pine View Crematory
❑Entombment Address
MCremation Queensbury, New York
Date Place Removed
Removal and/or Held
C112,❑and/or Address
F` Hold
to
0 Date Point of
.ithEITransportation Shipment
Es by Common Destination
iiis Carrier
Q Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
iiiiiiii Name of Funeral Home Wilcox & Regan funeral home 01 821
Address
Iiii 11 Algonkin St. , Ticonderoga, New York 12883
ne Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
l
CL
Permission is hereby granted to dispose of the human rem ' described above indicated.
Date Issued 8/2 9/2 01 7 Registrar of Vital Statistics ?vim
(sign to )
District Number 1 564 Place Town of Ticonderoga
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILI Date of Disposition 11301 n Place of Disposition TgMV.-,' Com pr l-r..
2 (address)
in
tfl
(section) (lot number) ( (grave number)
it
Ci Name of Sexton or Person in Charge,rof Premises
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Signature Title [Si(VOL
(over)
DOH-1555 (02/2004)