Foglietta Jr., Jerome PERMIT MUST ACCOMPANY'REMAINS TO DESTINATION 324
FORM BT-1,12/2010
STATE OF NEW HAMPSHIRE 1.BURIAL PERMIT NO
BURIAL TRANSIT PERMIT 2.CITY OR TOWN
3.DECEDENT'S NAME(First,Middle,Last) 4.SEX 5.DATE OF DEATH(Month,Day,Year)
JEROME SCOTT FOGLIETTA JR MALE APRIL 15,2017
6.AGE 7.DATE OF BIRTH(Month,Day,Year) 8.CITY,TOWN,OR LOCATION OF DEATH 9.COUNTY OF DEATH
30 Years NOVEMBER 29,1986 DOVER STRAFFORD
10.METHOD OF DISPOSITION(1.Burial 2.Temp.Entombment 3.Cremation 4.Donation 5.Mausoleum 6.Other): CODE: 3
11.PLACE OF DISPOSITION(Name of cemetery,crematory or other place) PINE VIEW CREMATORY
12.LOCATION (City/Town,State) QUEENSBURY,NY
13.DATE OF DISPOSITION(Refer to 19a) APRIL 21,2017
14.IF ENTOMBED(OR CREMATED)PLACE OF FINAL BURIAL
15.LOCATION OF FINAL DISPOSITION(City/Town,State)
16.FUNERAL DIRECTOR STARR BAKER 117.N.H.LIC.NUM ONLY 000
18.NAME AND LOCATION OF FACILITY(City/Town,State) BAKER FUNERAL HOME,QUEENSBURY,NY
19.COUNTER SIGNED AGENT(City Board of Heath/Sub-Register if app.) 20.CITY/TOWN 21.DATE ISSUED(Month,Day,Year)
JUDITH L CRETEAU DOVER APRIL 17,2017
22.IF STORED,BODY WAS PLACED IN(Name of Storage Vault) 23.DATE STORED(Month,Day,Year) 24.CITY/TOWN,STATE
25.SIGNATURE OF SEXTON OR PERSON IN CHARGE OF STORAGE VAULT 26.DATE ISSUED(Month,Day,Year)
27.TYPE OF DISPOSITION(Cremated,buried,etc.) 28.DATE OF DISPOSITION 29.NAME AND LOCATION OF CEMETERY OR VAULT
(Month,Day,Year) (City/Town,State)
(44) q/z y/0 2( 4IAIfa R a?81 1u 1. 12
30.SECTION 31.GRAVE NO. 32.SIGNATURE OF SEXTON OR PERSON IN CHARGE
ii `
This permit,after being signed by the Sexton or person in charge(or by the Funeral Director where there is no Sexton)must be forwarded within six days to
the clerk of the town in which the disposition takes place.