Frank, Dewey NEW YORK STATE DEPARTMENT OF HEALTH 737_
Vital Records Section Burial - Transit Permit
} Name First Mid Icf a 1111 Last Sex
Dewey LaBelle Frank Male
Date of Death Age If Veteran of U.S. Armed Forces,
May 2, 2012 84 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Moreau Street Address 16 Spruce Street
Manner of Death 0 Natural Cause ❑ Accident ❑ Homicide 0 Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
Medical Certifier Name Title
Robert Love, Dr.
Address
1 Iron Gate Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
tO City, Town or Village Moreau
= Date Cemeteryor Crematory
❑Burial .
May 3, 2012 Pine View Crematory
0 Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment
by Common Destination
, , Carrier
Date Cemetery Address
.y ❑ Disinterment
❑ Reinterment Date Cemetery Address
• Permit Issued to Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home 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
Permission is hereby granted to dispose of the human remai escribed above a indicated.
Date Issued o-3; a42, Registrar of Vital Statistics / ��- .C- a 9., -
(signature)
• District Number .5lo a Place /d--At'
z
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 05/03/2012 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) (lot number. (grave number)
Act;t+ S '1
Name of Sexton or Pe son in Charge f Premises � [�►��
(please print)
Signature ��� Title Cecim -- 1C
g
(over)
DOH-1555 (02/2004)