Koenig, Frederick NEW YORK STATE DEPARTMENT OF HEALTH 5%-f
Vital Records Section Burial - Transit Permit
is Name First Middle Last i Sex
Frederick Frank Koenig Male
Date of Death Age 1 If Veteran of U.S. Armed Forces.
08/04/2015 1 90 yrs. 1 War or Dates 1943-1945
:!.1;4 Place of Death Town of I Hospital, Institution or
City, Town or Village Hague i Street Address 89 Overbrook Road
MI
io Manner of Death IX)Natural Cause n Accident n Homicide n Suicide I I Undetermined n Pending
Itj Circumstances Investigation
PLI Medical Certifier Name Title
0 Glen Chapman M.D.
Address •
P.O. Box 29, Ticonderoga, New York 12883
M.:s Death Certificate Filed Town of District Number Register Number
City, Town or Village Hague 5653
it
Date ' Cemetery or Crematory
❑ Burial 08/06/2015 Pine View Crematory
Address
E]Cremation Queensbury, New York
Date I Place Removed
-0 n Removal , and/or Held
-- and/or Address
- Hold'
0
O Date Point of
NE Transportation Shipment
3 by Common Destination
Carrier
11 Disinterment Date Cemetery Address
❑ Reinterment Date Cemetery Address
Mi Permit Issued to ' Registration Number
Name of Funeral Home Wilcox & Regan Funeral Home 01 821
Address
iN 11 Algonkin St. , Ticonderoga, NY 12883
' ' Name of Funeral Firm Making Disposition or to Whom
'= Remains are Shipped, If Other than Above
Address
L
iin Permission is hereby granted to dispose of the human remains described above as indicated.
»> Date Issued 8/6/2 01 5 Registrar of Vital Statistics A , fl r, I n
(signature)
District Number 5653 Place Town of Hague
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
t~-
Date of Disposition Place of Disposition ex 0...0 elf v!'w..,.
W (address)
t/J
CC (section) (lot number (grave number)
0 Name of Sexton or Person in Charge of Premises
/Ii ._
Z A
(please print)
W Jr mAiot
Signature �— Title 4/04/4.
(over)
DOH-1555 (9/98)