VanNostrand, Frederick R - ; it- 3L0
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last 1 Sex Male
Frederick F. VanNostrand
Date of Death Age If Veteran of U.S. Armed Forces,
7/14/2012 74 War or Dates 1961-1967
1.., Place of Death Hospital. Institution or
Z Ca Town • 0 Lake Luzerne _ Street Address 383 East River Dr.
Manner of Death(]Natural Cause Q Accident El Homicide El Suicide El Undetermined El Pending
'Al _ Circumstances Investigation
'O Medical Certifier Name Title
William Orluk RPA-C
Address �`_
Chestertown,NY
Death Certificate Filed District Number Register Nuner
.. Town Xr t Lake Luzerne 565E
Date Cemetery or Crematory
❑Burial 7/16/2012 Pine View Crematory
Address
O Cremation i Queensbury,NY
Date Place Removed
Z❑Removal and/or Held
-. and/or ___ _ _ ,
i- Address
a Hold
0 Date Point of
N❑Transportation _ Shipment
5 by Common Destination
Carrier
Disinterment
Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Brewer Funeral Home, Inc. _ 00211
Address
24 Church St., Lake Luzerne,NY 12846
Name of Funeral Firm Making Disposition or to Whom
}" Remains are Shipped. If Other than Above
Address
Au
Permission is hereby granted to dispose of the human re ins descri•e• above as in icated.
Date Issued 1" I CD" I L Registrar of Vital Statistics A/1_ b' 414'YiC6,
rr /' n /�1,, / , . signature)
District Numbe (D Place Lii.. A.-tt A-A-C - 14 SIG
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
F- p /'
W Date of Disposition 1111.((1 Place of Disposition mVim, C w,.c{('orvL\
.2 (address)
W
Cl)
CC (section) A (lot number) /' (grave number)
GName of Sexton or Person in Charge of Premises t krf ii ., J10p11--
Zr (please print)
41 Signature i l� A Title aAAAA-,d'IL-
DOH-1555 (10/89) p. 1 of 2 VS-61