Frost, Gary '7L 1
NEW YORK STATE DEPARTMENT OF HEAL i H'
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Gary Vernon Frost Male
WAWA-- Date of Death Age If Veteran of U.S. Armed Forces,
March 20, 2017 68 War or Dates
Place of Death Hospital, Institution or
tu City, Town or Village Glens Falls Street Address Glens Falls Hospital
0 Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
❑ ❑ ❑ ❑ ❑ ❑
Circumstances Investigation
Medical Certifier Name Title
0: Dean Reali, M.D
Address
Hudson Headwaters Warrensburg, NY 12885
Death Certificate Filed District Number Register Number
City, Town or Village 5601 176°
El Burial Date Cemetery or Cr ,ry
iii4March 23, 2017 Pin 3matorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
iiiii Date Place P
ciRemoval and/or
and/or Address
Hold
Date Point of
Al Li Transportation Shipment
(it by Common Destination
0,: Carrier
❑ Disinterment Date Cemetery Address
_14,❑ Reinterment
Date Cemetery Address
Permit Issued to Registration Number
s Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
40 Name of Funeral Firm Making Disposition or to Whom
gi Remains are Shipped, If Other than Above
-Xi Address
6
4p Permission is hereby granted to dispose of the human remains described above as indicated.
° ` Date Issued 3 f 2'24 l'7 Registrar of Vital Statistics V �., 1
(signature
District Number 5601 Place G LSZV ,s re,,\\S I N V
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
6 ,_Date of Disposition 03/Z2017 Place of Disposition Quaker Road Queensbury,NY 12804 i� Bi), f Cr2- :i-,%-y
(address)
lik
i (section) lot number) (grave number)
aName of Sexton or s n 'n Charge of Premises t-v/% /i err/ .. �.
(please print)
4�✓'. e Signature Title Cr2, 1v
(over)
DOH-1555 (02/2004)