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Desourdy, Frank NEW YORK STATE DEPARTMENT OF HEALTH t ! Vital Records Section Burial ' r nsit Permit Name First Middle Last Sex Frank Joseph Desourdy Male Date of Death Age If Veteran of U.S. Armed Forces, June 4, 2016 84 War or Dates i— Plac ath _ Hospital, Institution or W City frow]r Village Kin SIUW ei Street Address 129 Dubes Road W, Manner of Death Friu Natural ause ❑ Accident ElHomicide ❑ Suicide ❑ Undetermined. ❑ Pending U Circumstances Investigation W Medical Certifier Name Title 0 Robert Beaty MD, Address 100 Broad St. Glens Falls, NY 12801 Death . icate Fileq i District Number Register Number City, Town r Village K,t s b u r 5762 ( <3 ❑Burial Date Cemetery or Crematory June 6, 2016 Pine View Crematorium ❑Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed z ❑ Removal and/or Held and/or Address Hold Moss Street Cemetery CD Date Point of il ❑Transportation Shipment co, by Common Destination p Carrier Date Cemetery Address ❑ Disinterment Date Cemetery Address ❑ Reinterment Permit Issued to Registration Number 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 Name of Funeral Firm Making Disposition or to Whom I— Remains are Shipped, If Other than Above E Address L' Wa.; Permission is hereby granted to dispose of the human remai described above as indicated. Date Issued 6.-�pt 20/6 Registrar of Vital Statistics \� L3.520_42--a-------___. (signature) District Number 5762 Place'©t k},A_ , N 4ce, —', I certify that the remains of the decedent identifie above were disposed of in accordance with this permit on: Lu Date of Disposition 06/06/2016 Place of Disposition Quaker Road Queensbury,NY 12804 E; (address) W CO (section) (lot number) (grave number) OName of Sexton or Person in Charge of Premises Afite, se""�Z se print) W Signature Title 44 (over) DOH-1555 (02/2004)