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Green Jr., Fredrick L CLI.t. # 3 Z NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Frederick L.Green Jr. Male Date of Death Age If Veteran of U.S.Armed Forces, 04/15/2023 76 Years War or Dates F... Place of Death Hospital,Institution or WCity,Town or Village Queensbury Town Street Address Warren Center for Rehabilitation and Nursing 0 Manner of DeathIZI Natural Cause Accident Ei Homicide Suicide Undetermined Pending Circumstances Investigation W Medical Certifier Name Title 0 Wendy Steinhacker PA Address 42 Gurney Ln,Queensbury Town,New York 12804 Death Certificate Filed Town Of Queensbury District Number Register Number City,Town or Village 5657 63 Burial Date Cemetery,Crematory or Facility Name .M 04/20/2023 Pineview Crematory Entombment _ Address ©Cremation Queensbury Town,New York Donation Ol❑Removal Date Place Removed and/or and/or Held F— Hold Address lA0� Date Point of Cl) Transportation Shipment a by Common Carrier Destination Disinterment Date Cemetery Address El Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Densmore Funeral Home Inc 00448 Address 7 Sherman Ave,Corinth,New York 12822 Name of Funeral Firm Making Disposition or to Whom i- Remains are Shipped,If Other than Above 2 Address Q W IL Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 04/19/2023 Registrar of Vital Statistics Caroline Hildegarde Barber(Electronically Signed) (signature) District Number 5657 Place Town Of Queensbury I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: W Date of Disposition y 12l (i3 Place of Disposition 1.- _ liz (address) W N /section) /f (lot number/ ri (grave number) CC gName of Sexton or Person in Charge of Pre 'ses `'lease print) W Signature Title /T O< DOH-1555(07/18)pi of 2 ;" 1Cc: Public Health Law Sec. 4145(2b) Receipt f Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License# 4