DeWolfe, Frederick NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Frederick G. DeTgolfe Male
Date of Death Age If Veteran of U.S. Armed Forces,
1/12/96 80 War or Dates No
Place of Death Hospital, Institution or
City, Town or Village T/Of Moreau Street Address 45 Spier Falls Rd.
Manner of Death❑Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined El Pending
Circumstances Investigation
Medical Certifier Name Title
John R Weinhold MD
Address
102 Park St.Glens Falls,NY
Death Certificate Filed District Number Register Number
City, Town or Village T/Of Moreau L i
Date Cemetery or Crematory
❑Burial 1/16/96 Pine View Crematorium
Address
❑X Cremation Queensbury,NY
Date Place Removed
0❑Removal and/or Held
and/or Address
>
Hold
O Date Point of
N❑Transportation Shipment
by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home SULLIYAN.MINANAN 8 POTTER,INC. 01877
Address
GLENS FALLS NY 12801-4454
Name of Funeral Firm Making Disposition or to Whom
" Remains are Shipped, If Other than Above
sim
Address
Permission is hereby granted to dispose of the human remains described a ove as indicated.
Date Issued — Registrar of Vital Statistic
(signature)
District Number z15(0� Place Q(,J/V 0 F Q E/�CI
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition ` 1` Place of Disposition s / ezE'; y/
(address)
iUJ
N
(section) 1 (lot number) (grave number)
GName of Sexton r Person in Charge of Premises
(please print)
Signature Title S�
DOH-1555 (10/89) p. 1 of 2 VS-61