Frost, Samuel I 1-
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
r; Name First Middle Last Sex
Samuel Frost Male
_ Date of Death Age If Veteran of U.S. Armed Forces,
April 14, 2017 96 War or Dates Navy
„ Place of Death Hospital, Institution or
City, Town or Village Queensbury Manner of Death
Street Address 59 Mountain View Lane
n Natural Cause Accident Homicide n Suicide n Undetermined Pending
Circumstances Investigation
Medical Certifierrf Name Title
I
Christopher Hoy,MD
, Address
Queensbury,NY
% Death Certificate Filed District Number gj.s er Number
City, Town or Village Queensbury, NY 5657 ��/J
❑Burial Date Cemetery or Crematory
April 18, 2017 Pine View Crematorium
❑Entombment Address
❑x Cremation 51 Quaker Road, Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
N
O Date Point of
NTransportation Shipment
'p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
, Address
53 Quaker Road, Queensbury, NY 12804
:, Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
>{ Permission is hereby granted to dispose of the human remains describe -#hove asrindicated.
Date Issuedl---111�1a01—) Registrar of Vital Statistics 'c'f- c-\__ q ILA-,
(signature)
District Numb 9`r1 Place Icnu - 0— " ( ��
I certify that the remains of the decedent identified above were disposed of in acc rdanee with this permit on:
W Date of Disposition•y/`l /9//7 Place of Disposition rPt"hOA)I C/,Q,,.y�49.-,/
2 / (address)
W
Cl)
0 (section) (lotpumber) (grave number)
QName of Sexton Per in Charge of Premises �1,t/. ,- oar/Le-I.-he
Z (please print)
W
Signature / Title C p�i-ci.cares,,/
f (over)
DOH-1555(02/2004)