Bingham, Frederic Al g5 7
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Frederic Nettleton Bingham Male
Date of Death Age If Veteran of U.S. Armed Forces,
December 3, 2015 65 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
CA Manner of Death Natural Cause ❑ Accident n Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
Medical Certifier Name Title
Suzanne Rayeski, Dr.
Address
170 Warren Street Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 D7Vi
0 Burial Date Cemetery or Crematory
December 4, 2015 Pine View Crematory
❑Entombment Address
-- ®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
RemovalI 'i and/or Held
and/or Address
Hold
Date Point of
0 pi Transportation Shipment
by Common Destination
Carrier
Date Cemetery Address
El Disinterment
Date Cemetery Address
I I Reinterment
Permit Issued to Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home-SGF 01078
Address
136 Main Street, South Glens Falls NY 12803
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
4 Permission is hereby ranted to dispose of the human remains des ri e al,a Gated.
Date Issued aD/ Registrar of Vital Statistics 4 -
_ (signature)
District Number 1v0/ Place ��,�.,, Aii// , /V /
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 12/04/2015 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
ili
t (section (lot number) (grave number)
Name of Sexton or Person in Ch a of Premises 1 m osli r I lin e(/'
(please print)
Signature 'i Title dr if ASk/
(over)
DOH-1555 (02/2004)