Garafalo, John NEW YORK STATE DEPARTMENT OF HEALTH to'1
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
John P Garafalo Male
Date of Death Age If Veteran of U.S. Armed Forces,
12/99/2011 92 years War or Dates
-- Place of Death Hospital, Institution or
W City, To V* CX Glens Falls Street Address glens Falls Hospital
O Manner�o Death JNatural Cause 0 Accident 0 Homicide 0 Suicide Undetermined Pending
LLlC Circumstances Investigation
iii Medical Certifier Name Title
C Scott Biasetti M l
Address
100 Park Street Glens Falls, N Y 12801
Death Certificate Filed District Number Register Number
City, Tovel rYVilinekX (;IPnc Falls 5601 568
!`: ['Burial Date Cemetery or Crematory
❑Entombment ,2/20/2011 Pine View Crematorium
Address
❑grerrmation Oueensbury,'NY 12804
Date Place Removed
Z Removal and/or Held
O ❑and/or Address
f= Hold
Cl)
O Date Point of
N0 Transportation Shipment
C by Common Destination
Carrier
ElDisinterment 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 Street Queensburv, N Y 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
t
LU
IL
Permission is hereby granted to dispose of the human remains described above as indicated.
Ei Date Issued 12/28/2011 Registrar of vital Statistics kiJ Cx..NJYYJz.v.0
(signature
District Number 5601 Place Glens Falls
"' I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
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Lip! Date of Disposition 1 1.3 ) it Place of Disposition oft/v v0 C opctoc.
2 (address)
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ifs
>Z (section) ``(l-o-t number (grave number)
Name of Sexton or Person in Charge f Premises jc,s�cg)�Pft„0l�
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ff (please print)
Signature Title r vkmpa0L
(over)
DOH-1555 (02/2004)