Mazzeo, Mario L �aqq
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last 7SeMario L.Mazzeo
Date of Death Age If Veteran of U.S.Armed Forces,
03/21/2020 96 Years War or Dates WWII
Place of Death Hospital,Institution or
WCity,Town or Village Lake George Town Street Address 33 Birch Avenue, Lake George Town, New York 12845
'p Manner of Death ❑X Natural Cause Accident Homicide Suicide ❑Undetermined Pending
C.) Circumstances Investigation
QW Medical Certifier Name Title
Robert Reeves MD
Address
3 Irongate Center,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Lake George 5651 2
Burial Date Cemetery,Crematory or Facility Name
03/26/2020 Pine View Crematory
Entombment Address
KCremation Queensbury Town,New York
❑Donation
zRemoval Date Place Removed
and/or and/or Held
~ Hold Address
t�
O
IL Date Point of
N Transportation
p by Common Shipment
Carrier Destination
Disinterment
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
Remains are Shipped,If Other than Above
Address
W
IL Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 03/26/2020 Registrar of Vital Statistics Patricia��fc�inney Schurter��lectronicall Signed
(signature)
District Number 5651 Place Lake George, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
H
Z Date of Disposition j—79,7o-10 Place of Disposition
(address)
W
W (section) (lot number/ (grave number)
aName of Sexton or Person in Ch a of Premises
Z (please print)
W Signature Title l
DOH-1555(07/18)p of 2
Public Health Law Sec. 4145(2b) 013470
Receipt
Human remains of .,� `. ' ��, delivered on , 20
i
r
Pine,View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License# '