June, Frederick ) .z
NEW YORKSTATE DEPARTMENT OF HEALTH 4Y � l
Bureau of Vital Records Burial - Transit Permit
Name First Middle Last Sex
Frederick June Male
Date of Death Age If Veteran of U.S.Armed Forces,
10/13/2022 89 Years War or Dates
F.. Place of Death Hospital,Institution or
W City,Town or Village Glens Falls Street Address Glens Falls Hospital
p• Manner of Death lI Natural Cause Accident ❑Homicide Suicide Undetermined ❑Pending
Circumstances Investigation
W Medical Certifier Name Title
G Mathew Varughese DO
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed City Of Glens Falls District Number Register Number
City,Town or Village 5601 527
Burial Date Cemetery,Crematory or Facility Name
i 10/18/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
0❑Removal Date Place Removed
and/or and/or Held
~
N Hold Address
O
O. Date Point of
U) Transportation
p by Common Shipment
Carrier Destination
Date Cemetery Address
Disinterment
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Alexander Baker Funeral Home 00037
Address
3809 Main St,Warrensburg,New York 12885
Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped,If Other than Above
2 Address
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 10/17/2022 Registrar of Vital Statistics Megan (EfectronicaffySigned)
(signature/
District Number 5601 Place City Of Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 1 p 1 I3i Z Z -�� �
Place of Disposition v
2 (address)
W
CC N (section) A (lot numbers (grave number)
8 Name of Sexton or Person in Charge of P emises ()Sir-,
—,
Z j /ilease print)
W Signature / Title ru fl
DOH-1555(07/18)p t of 2
Public Health Law Sec. 4145(2b) "� 3
Receipt
Human remains of ' delivered on , 20
I
ii_ Pine View Cemetery Representing the funeral home named on burial,permit
Official Funeral Directors Reg.or License# - P
i
1