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Alexy, Fred I !y - .i,,,/ 1 NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit iiii Name First Middle Last Sex XI Fred H. Alexy Male Date of Death Age If Veteran of U.S. Armed Forces, iiiii March 26, 2014 83 War or Dates iPlace of Death Hospital, Institution or City, Town or Village Queensbury Street Address 37 Overlook Drive gi Manner of Death Natural Cause Accident I I Homicide Suicide Undetermined Pending Circumstances Investigation Medical Certifier Name Title gi Robert Evans Address :_:: Irongate,Glens Falls,NY 12801 Death Certificate Filed District Number Regis©r Number . City, Town or Village Town of Queensbury 5657 ', 2 ❑Burial Date Cemetery or Crematory March 31, 2014 Pine View Crematorium ❑Entombment Address ❑x Cremation 21 Quaker Road, Queensbury, NY 12804 Date Place Removed ZZ I I Removal and/or Held and/or Address F Hold 0 Date Point of yTransportation Shipment a by Common Destination Carrier Disinterment Date Cemetery Address Reinterment Date Cemetery Address ': Permit Issued to Registration Number :::: Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596 Address 407 Bay Road, Queensbury, NY 12804 Name of Funeral Firm Making Disposition or to Whom 1 Remains are Shipped, If Other than Above Address g Permission is hereby granted to dispose of the human emains described arbove as indicated. Date Issued a at/ ( Registrar of Vital Statistics G`. �, (-J � (signature) District Number 5657 Place Town of Queensbury I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z , Place of Disposition Date of Disposition �/_ � P/ti',� yam,/ Ct.A.4 so iti 2 (address) W CO IY (section) Aro t number) (grave number) pName of Sexton or r n ' harge of Premises SCa ,j At t„/Ameid z (please print) W Signature ✓Nl/� Title Z (over) DOH-1555(02/2004)