Piskothy, Frank . � � # I70
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
r`.-. Name First Middle Last Sex
' rz
'; Frank W. Piskothy Male
Date of Death Age If Veteran of U.S. Armed Forces,
f!' March 5, 2015 72 War or Dates 1960—1962 Navy
% Place of Death Hospital, Institution or
City, Town or Village Queensbury Street Address 19 Sugarbush Road
Manner of Death n Natural Cause Accident Homicide Suicide ❑Undetermined x Pending
Circumstances Investigation
Medical Certifier Name Title
n Timothy Murphy,Coroner
Address
t. 100 Park Street,
,Glens Falls,NY 12801
?"' Death Certificate Filed District Number Reg4Number
City, Town or Village Queensbury,NY 5657
❑Burial Date Cemetery or Crematory
March 9, 2015 Pine View Crematorium
❑Entombment Address
CI Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
ZZ n Removal and/or Held
2 and/or Address
Hold
CO
0 Date Point of
Nn Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
pi Renterment Date Cemetery Address
', ; Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
ff
Address
i 407 Bay Road, Queensbury,NY 12804
,; Name of Funeral Firm Making Disposition or to Whom
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Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human 'n describe ve indicated.
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Date Issued _ais Registrar of Vital Statistics " 0Jo .4
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_� (signature1
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t District Number 5657 Place Queensbury,NY
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I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z I � -
W Date of Disposition ��11�/S Place of Disposition Inc ,.,, �- r,�..
g (address)
W
CO
O (section) //flot number) (grave number)
p Name of Sexton or Person in Charge of Premises GZ,S.+ 3e
Z (p1e se print)
W Title (d1+1�f
Signature
(over)
DOH-1555(02/2004)