Wormer, Frank NEW YORK STATE DEPARTMENT OF HEALTH tt " I
Vital Records Section ws Burial - Transit Permit
Name First Middle Last Sex
Frank A. Wormer Male
Date of Death Age If Veteran of U.S. Armed Forces,
July 20, 2012 91 War or Dates
1. Place of Death Hospital, Institution or
:Z City, Town or Village Queensbury Street Address Stanton Nursing & Rehab Centre
ciManner of Death n Natural Cause Accident n Homicide Suicide 1 I Undetermined Pending
US Circumstances Investigation
us Medical Certifier Name Title
Roslyn Socolof,MD
Address
Sherman Ave,Queensbury,NY 12804
Death Certificate Filed District Number Regjster Number
City, Town or Village Queensbury C.•�l
❑Burial Date Cemetery or Crematory
July 23, 2012 Pine View Crematorium
❑Entombment Address
❑x Cremation 21 Quaker Road, Queensbury,NY 12804
Date Place Removed
ZZ n Removal and/or Held
and/or Address
t' Hold
N
0 Date I Point of
051 I Transportation I Shipment
a by Common Destination
Carrier _
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
M1. Name of Funeral Home Regan & Denny Stafford Funeral Home 1 01443
Address
53 Quaker Road, Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
:'N Address
.te
` Permission is hereby granted to dispose of the human remai described above 'Indicated.
Date Issued 2-L3 - Z Registrar of Vital Statistics A'
(signature)
District Number 6•k05---i Place Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition ny5. Place of Disposition Vick) CoAdtfifru..
2 (address)
CO
0 (section) < (lot number)(-- (grave number)
QName of Sexton or Person in Charge of Premises /hro4r J[er
Z 4- 2-- D (please print)
W
Signature Title Cv „il-0(1
(over)
DOH-1555(02/2004)