Arpaio, Pasquale NEW YORK STATE DEPARTMENT OF HEALTH 1 L N Si
Vital Records Section Burial - Transit Permit
LAI Name First Middle Last Sex
Pasquale Thomas Arpaio
Male
al Date of Death Age If Veteran of U.S. Armed Forces,
06/12/2018 64 Years War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Fails Hospital
Manner of Death Natural Cause 0 Accident D Homicide 0 Suicide Undetermined �Pending
,714`4 Circumstances Investigation
Medical Certifier Name Title
z
Scott Biasetti MD
� ` Address
, 100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 294
gi-
52,04
❑Burial Date Cemetery or Crematory
06/18/2018 Pine View Crematory
❑Entombment04 Address
®Cremation QueensburyTown, New York
Date Place Removed
Removal and/or Held
and/or Address
,- Hold
a. Date Point of
0 Transportation Shipment
.„ by Common Destination
Carrier
❑Disinterment Date Cemetery Address
it A❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D Baker Funeral Home 01130
ii Address
Iff 11 Lafayette St,Queensbury,New York 12804
._,. Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
' Address
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 06/13/2018 Registrar of Vital Statistics qg6ertA Curtis(Etectronica1 y Signed)
(signature)
District Number 5601 Place Glens Falls, New York
,r
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition trl Za ig Place of Disposition ,Qft,(J.,.,, ali-6- V
.t (address)
,CY
(section) NA
(grave number)
Name of Sexton or Person in Charge of Premises 51,tp' - tit number)
k A (pleas pnnt)
' Signature A Title 's
„,,,,
(over)
DOH-1555 (02/2004)