Ament, Fredrick Paul NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Frederick Paul Ament Male
Date of Death Age If Veteran of U.S.Armed Forces,
11/10/2021 65 Years War or Dates
�- Place of Death Hospital,Institution or
W City,Town or Village Glens Falls Street Address Glens Falls Hospital
ip Manner of Death NINatural Cause I=1 Accident 0 Homicide El Suicide Undetermined Pending
U
Circumstances Investigation
WL7 Medical Certifier Name Title
Kasandra Frasier PA
Address
100*ark St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 517
IDBurial Date Cemetery,Crematory or Facility Name
11/17/2021 Pine View Crematory
ID Entombment Address
U Cremation Queensbury Town,New York
El Donation
O Removal Date Place Removed
and/or and/or Held
- Hold Address
O _
NTransportation Date Point of
p by Common Shipment
Carrier Destination
ElDisinterment 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
Name of Funeral Firm Making Disposition or to Whom
p- Remains are Shipped,If Other than Above
Address
CC
W _
L
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11/16/2021 Registrar of Vital Statistics p6ertAndrew Curtis(ECectronicalTySigned)
(signature)
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:
17
I'
Date of Disposition j fl '( "I Place of Disposition tU
UJ
2 (address)
W
CC CC (section) Allot number) �` (grave number)
GName of Sexton or Person in Charge of Premises (U 414
z (pl se print)
W Signature Title 4 �NL
DOH-1555(07/18)p 1 of 2
1.01 5345
Public Health Law Sec. 4145(2b)
Receipt
Human remains of y, �. i delivered on , 20
Pine View Cemetery Representing the funeral home named on burial prmit
Official Funeral Directors Reg.or License#