Williams, Frank NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
:▪ . Frank Roger Williams Male
.: Date of Death Age If Veteran of U.S. Armed Forces,
March 22, 2015 35 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Gansevoort Street Address 6 Mountain Rd.
Manner of Death Natural Cause Accident Homicide Suicide Undetermined x Pending
Circumstances Investigation
Medical Certifier Name Title
ni Michael Sikirica
.. Address
50 Broad Street,Waterford,NY 12188
Death Certificate Filed District Number Register Number
City, Town or Village Moreau 4562 /27
.. ❑Burial Date Cemetery or Crematory
March 25, 2015 Pine View Crematory
❑Entombment Address
❑x Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
r Hold
Cl)
O Date Point of
O. Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
I
Reinterment Date Cemetery Address
• Permit Issued to Registration Number
Name of Funeral Home Regan& Denny Funeral Home 01444
Address
94 Saratoga Avenue, South Glens Falls,NY 12803
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
ex. Permission is hereby granted to dispose of the human remains described above as indicated.
ii Date Issued N�y1j J Registrar of Vital Statistics ALC�,wyL 41 6 —
(signature)
District Number 4562 Place Moreau
I certify that the remains of the decedent identified above were disposed'of
in accord ce with this permit on:
W Date of Disposition 32.l( r Place of Disposition P01L'!E. U //,..✓ f..q ik't
2 (address)
W
CO
O g (section) 4umbe�)�N (grave number)
O /p Name of Sexton or Pe Charge of Premises •�- w''
Z (please print) /41
Signature Title C 1'3. ,-
(over)
DOH-1555(02/2004)