Ashe, Francis NEW YORK STATE DEPARTMENT OF HEALTH 1 It 15
146
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Francis Ashe Male
Date of Death Age If Veteran of U.S. Armed Forces,
April 28, 2012 49 War or Dates
., Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Kt
iss, Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
IS Circumstances Investigation
us Medical Certifier Name Title
3i Michael Adams,MD
iii Address
Rt. 9 South Glens Falls,NY 12803
na' Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 I q 7
❑Burial Date Cemetery or Crematory
El Entombment May 3, 2012 Pine View Crematorium
Address
❑X Cremation 21 Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
2 and/or Address
�" Hold
N
0 Date Point of
N Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
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
E, Address
If:
til
Permission is hereby granted to dispose of the human remains descri ed abov as . ' ated.
Date Issued Qr/p3AV-- Registrar of Vital Statistics
(signature)
District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance� with this permit on:
W Date of Disposition S-(1- ('1 Place of Disposition '�1KAA,cw (./ov-i <<,�,
2 (address)
W
U)
ZName0 (section) 4 (lot numbe (grave number)
of Sexton or Per on in Charge of Premises L hrtsk ,)t,,,,vH-
W I (please print)
Signature 7L. , Title Ce4-tirAr d12
(over)
DOH-1555(02/2004)