Frost, Richard George ,4' LF It- q 1—)
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Richard George Frost Male
Date of Death Age If Veteran of U.S.Armed Forces,
10/14/2022 67 Years Waror Dates
i, Place of Death Hospital,Institution or
Z City,Town or Village Fort Edward Town Street Address 14 Olive Street,Fort Edward Town,New York 12828
iLl
p Mannerof Death 1:1Natural Cause ❑Acadent Homicide ❑Suicide ❑Undetermined Pending
W Circumstances Investigation
WMedical Certifier Name Title
G Robert Lemieux Coroner
Address
415 Lower Main Street,Hudson Falls Village,New York 12839
Death Certificate Filed Town Of Fort Edward District Number Register Number
City,Town or Village 5755 n
Burial Date Cemetery,Crematory or FacilityView Name
10/1812022 Pine Crematory
Entombment Address
Cremation Queensbu y Town,New York
nDonation -
21 1Removal Date Place Removed
and/or and/or Held
~ Hold Address
N
0
G. Date Point of
N Transportation Shipment
p by Common
Carrier Destination
Date Cemetery Address
Disinterment
El
Re interment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M B Kikner Funeral Home-South Glens Falls 01078
Address
136 Main St,S Glens Falls,New York 12803
Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped,If Otherthan Above l
.N Address )
IS
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 10/17/2022 Registrarof Vital Statistics flaw GAfaliorrey(Thctmav ySktts4
(signature)
District Number 5755 Place Town Of Fort Edward
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition I°liCi 7 i_ Place of Disposition /J
LLI ladt6ess)
W
O (section) 4, 44.;_,
I/ot l,,,,„vi tri
lgraxnumber/
0 Name of Sexton or Person in Charge of P ' es `pprint)
Z (
uJ Signature Title ` 17' 4 { "ie
DOH-1555(07/18)p t of 2
Public Health Law Sec. 4145(2b)
Receipt
Human remains of 1 delivered on , 20 '-
Pine View Cemetery R epresenting-the funeral honie-name9d on burial permit
+
Official Funeral Directors Reg. or License#