Cain, Frank NEW YORK STATE DEPARTMENT OF HEALTH 01
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Frank Williams Cain Male
Date of Death Age If Veteran of U.S. Armed Forces,
May 27, 2014 71 War or Dates
2 Place of Death Hospital, Institution or
w City, Town or Village Glens Falls Street Address Glens Falls Hospital
W' Manner of Death 'Di Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
Ili Medical Certifier Name Title
O Eric Pillemer, M.D. Dr.
Address
102 Park Street Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village 5601 2L1 g
❑Burial Date Cemetery or Crematory
May 28, 2014 Pine View Crematorium
_❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
and/or Address
p Hold
0 Date Point of
a. ❑Transportation Shipment
(i) by Common Destination
0 Carrier
Date Cemetery Address
❑ Disinterment
Date Cemetery Address
❑ Reinterment
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
)—. Remains are Shipped, If Other than Above
• Address
I :
111
G' Permission is hereby granted to dispose of the human remains described above as indicated.
Registrar of Vital Statistics VJ
Date Issued �J�$�` i t� g CAM-y--st. `iV
(signature)
District Number 5601 Place (t 4j- q,,0\S
• I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 05/28/2014 Place of Disposition Quaker Road Queensbury,NY 12804
2 (address)
W`
I (section) /f ! (lot ber) (grave number)
3 Name of Sexton or Person . Charge of Premises (((fff/F/ 6+rF
0 (please print)
W` Signature L/70 Title '' '/`
(over)
DOH-1555 (02/2004)