Dicarlo, Adam Joseph "
NEW YORKSTATE DEPARTMENT OF HEALTH f1 2-06Burlap - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Adam Joseph Dicarlo Male
Date of Death �Age If Veteran of U.S.Armed Forces,
03/24/2020 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
Q Manner of Death FRI Natural Cause Accident Homicide Suicide Undetermined Pending
QW Circumstances Investigation
Medical Certifier Name Title
Roslyn Socolof MD
Address
42 Gurney Ln,Queensbury Town,New York 12804
Death Certificate Filed District Number Register Number
City,Town or Village Queensbury 5657 54
Burial Date Cemetery,Crematory or Facility Name
03/27/2020 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
0 Removal Date Place Removed
and/or and/or Held
t- Hold Address
N
O
IL Date Point of
U)❑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
1
W
n' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 03/27/2020 Registrar of Vital Statistics Carolire-W,-fde,4arde BarAer(E&-trowi7alySoned)
(signature)
District Number 5657 Place Queensbury, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
l—
Z Date of Disposition 12,1 ZO Place of Disposition
W
� /address/
W
it N (section) (lot number) (grave number)
aName of Sexton or Person in Charge of Premises
Z (PI—Print)
W Signature Title
DO H-1555(07/18)p t of 2
Public Health Law Sec. 4145(2b) 0 13 4 9 5
Receipt
Human remains of ' delivered on 20
Pine View Cemetery Representing the funeral home named on.burial permit
Official Funeral Directors Reg.or License#