Haux, III. Frank 0 41 1i l
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Frank A.Haux Ill Male
Date of Death Age If Veteran of U.S. Armed Forces,
01/31/2018 88 Years War Or Dates 1946-1949
Place of Death Hospital, Institution or
ZCity, Town or Village Glens Falls Street Address The Pines At Glens Falls Center For Nursing&Rehabilitation
Manner of Death Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
Ili Medical Certifier Name Title
0 Kenneth France MD
Address
• 170 Warren St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 62
El Burial Date Cemetery or Crematory
02/02/2018 Pine View Crematory
"'Entombment Address
®Cremation Queensbury Town, New York
Date Place Removed
• ❑Removal and/or Held
and/or Address
Hold
CO
Date Point of
❑Transportation Shipment
i
by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
-, Permit Issued to Registration Number
• Name of Funeral Home Maynard D Baker Funeral Home 01130
Address
11 Lafayette St,Queensbury,New York 12804
µ° Name of Funeral Firm Making Disposition or to Whom
W Remains are Shipped, If Other than Above
Address
Uf
0` Permission is hereby granted to dispose of the human remains described above as indicated.
• Date Issued 02/02/2018 Registrar of Vital Statistics Weber t A Curtis(ETctronica1TySigned)
', (signature)
i District Number 5601 Place Glens Falls, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
r.
W Date of Disposition Zis(i3 Place of Disposition f.ittJ t4,--.4._,
(address)
N
iZ (section) , (lot number) (grave number)
2 Name of Sexton or Person in Charge of Premise tA,,4i'.. s J /
Z (p/ se print)
t l Signature Z Title re4011 .4
(over)
DOH-1555 (02/2004)