Kingsley, Frank NEW YORK STATE DEPARTMENT OF HEALTH f- ` ' 41 73
Vital Records Section Burial - Transit Permit
Name First Middle Last I Sex
Frank William Kingsley Male
Date of Death Age If Veteran of U.S.Armed Forces,
Feb 10, 2011 68 War or Dates -0-
tPlace of Death Hospital, Institution or
,, City,TodivaioNtilizipc Glens Falls Street Address Glens Falls Hospital
WManner of Death❑ Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
LU Ui Medical Certifier Name Title
Marvin Davidowitz, MD
Address
100 Park St., Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City, Glens Falls 5601 (p
❑Burial Date Cemetery or Crematory
Feb 14, 2011 Pine View Crematorium
❑Entombment Address
aeremation Tn of Queensbury, NY
Date Place Removed
z ❑ Removal and/or Held
O and/or Address
E Hold
U Date Point of
C3 Transportation Shipment
an, ❑
by Common Destination
O Carrier
Date Cemetery Address
❑ Disinterment
Date Cemetery Address
❑ Reinterment
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc.
Address
P.O. Box 67, 68 Main Street Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
EC
a. Permission is hereby ranted to dispose of the human remains descririai above in ' e .
Date Issued 0 /Y 208 Registrar of Vital Statistics
(signature)
District Number �601 Place City of r;1 Pns fa11 s, NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w Date of Disposition t3 'l igli Place of Disposition T'nt U'itJ 6r'c' d t��v
2 (address)
Wco
44; (section) (lot number)/ - (grave number)
cs• Name of Sexton or P r on in Charge Premises (1(1; "op�( nr/t}
z i (please print)
W Si• nature Title CR,E. M A- a(L
(over)
DOH-1555 (02/2004)