Foster II, Frederick vital Necoras oection Idol I CI I - I I Q 11 I,71 L r iT 1 1 u 1 l{. 1,50
Blame First Middle Last Sex
}Frederick L Foster II Male
Date of Death Age If Veteran of U.S.Armed Forces,
i. December 24, 2015 7 I War or Dates 0 L v7 _ j q
Z Place of Death Hospital, Institution or
W City,Town,or Village Glens Falls Street Address Glens Falls Hospital
G Manner of Death Et Natural Cause ❑ Accident Eli Homicide 0 Suicide n Undetermined n Pending
W Circumstances Investigation
O Medical Certifier_ Name • Title
m _J vGi L.uic-rf 5Z-f 2iCZ_ iNl
d Address
`t 13Pvvic:Q ¶TR-e-eT GLFvtS �t-.-5 inn i or
Death Certificate Filed / District Number Y Register Number
City,Town or Village Glens Falls 5 t� 1 b
❑Burial Date Cemetery or Crematory
December 31, 2015 Pineview Crematorium
❑Entombment Address
G 0 Cremation Town of Queensbury Queensbury, NY 12804
Date Place Removed
0 El Removal and/or Held
and/or Address
I' Hold
0 Date Point of
4 El Transportation Shipment
d by Common Destination
Carrier
Date Cemetery Address
a ❑Disinterment
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Jillson Funeral Home, Inc. 00885
Address
46 Williams Street, Whitehall, New York 12887
~ Name of Funeral Firm Making Disposition or to Whom
ec Remains are Shipped, If Other than Above
W Address
0.
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued )2/Z-(3-1 15 Registrar of Vital Statistics W CAJly t- V-)--A4C5q
(signature)
District Number Cj h O) Place Glens Falls,New York
F I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2
w Date of Disposition 12/31/2015 Place of Disposition Pineview Crematorium
2 (address)
W
44
(section) (lot nypiber) (grave number)
O Name of Sexton or P on in harge of Premises 44-/ ,,I. ( ..wt c
W (please print)
Signature Title ._re-Mevi79.---
(over)
DOH-1555 (02/ 04)