Wheeler, Frederick it sot
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
:.,, Name First Middle Last Sex
cr� : Frederick Wheeler Male
c • Date of Death Age If Veteran of U.S. Armed Forces,
:, : August 4,2014 79 War or Dates
'•. Place of Death Hospital, Institution or
City, Town or Village Queensbury Street Address 546 West Mountain Road
Manner of Death �gl
1Natural Cause I (Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
: Medical Certifier Name Title
•, Eric Pillemer MD
1 Address
.,so Glens Falls Hospital, 100 Park St, Glens Falls,NY 12801
::•:::: Death Certificate Filed District Number Rester Number
; :;: City, Town or Village Queensbury 5657 -")a'. D Burial Date Cemetery or Crematory
August 5, 2014 Pine View Crematorium
❑Entombment Address
0 Cremation Quaker Road, Queensbury,NY 12804
Date Place Removed
ZI I Removal and/or Held
and/or Address
H Hold
U)
0 Date Point of
I I Transportation Shipment
p by Common Destination
Carrier
,Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
;r : Permit Issued to Registration Number
�° : Name of Funeral Home Regan Denny Stafford Funeral Home 01443
.'..;:. Address
: 53 Quaker Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
:•,::• Permission is hereby granted to dispose of the human emains described above
rassiindicated.
Date Issuedt l3I Registrar of Vital Statistics
(signature)
k . District Number 5657 Place Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z 'p
W Date of Disposition (0b 1 f 1 Place of Disposition rAt,V+w 64-Aor,....
2 (address)
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Cr)
CL (section) /�//�lot number) (grave number)
pName of Sexton or Person in Charge of Premises G Ar ttpbi Jee Jtt`-
Z (plea print)
Lu Signature �— Title C r tiPi6
9 -
(over)
DOH-1555(02/2004)