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Augusta, Franklin it 3 NEW YORK STATE DEPARTMENT OF HEALTH _ 1 13 Vital Records Section Burial - Transit Permit Name First Middle Last Sex Franklin B. Augusta Male Date of Death Age If Veteran of U.S. Armed Forces, May 24,2013 71 War or Dates in,; Place of Death Hospital, Institution or Z. City, Town or Village Glens Falls Street Address Glens Falls Hospital QManner of Death +Xi Natural Cause I I Accident I I Homicide Suicide Undetermined Pending vCircumstances Investigation t1 Medical Certifier Name Title E Suzanne Blood,MD Address 161 Carey Road,Queensbury,NY 12804 Death Certificate Filed District Number Register Number ' . ` City, Town or Village Glens Falls 5601 2a ❑Burial Date Cemetery or Crematory May 28,2013 Pine View Crematory O Entombment Address ©Cremation 21 Quaker Rd., Queensbury, NY 12804 Date Place Removed Z Removal and/or Held O and/or Address E Hold co 0 Date Point of O. y Transportation Shipment p by Common Destination Carrier Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Alexander-Baker Funeral Home 00035 Address 3809 Main Street,Warrensburg,NY 12885 Name of Funeral Firm Making Disposition or to Whom 1— Remains are Shipped, If Other than Above Address Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 5/2& i3 Registrar of Vital Statistics U, C,M1 .0A. S(� (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: LIJ Date of Disposition (3)113 Place of Disposition CK,c ipt N,,.„ 2 (address) 111 CI) IBC (section) ot nmber) (grave number) p Name of Sexton or Person in harge of Pre ises 774,°111.- �e4NO Z ( a print) W Signature L Title C(ZEAi410(t (over) DOH-1555 (02/2004)