Fiore, Guy NEW YORK STATE DEPARTMENT OF HEALTH # 51C(
Vital Records Section 4 .- 1 Burial - Transit Permit
Name First Middle Last Sex
GUY R. FIORE Male
Date of Death I Age If Veteran of U.S. Armed Forces,
Nov 19, 2011 I 84 War or Dates Marines
}- Place of Death Hospital, Institution or
ZCity, Town or Village Glens Falls, NY Street Address Glens Falls Hospital
ci Manner of Death it Natural Cause ❑Accident ElHomicide ❑Suicide ElUndetermined ❑Pending
LU Circumstances Investigation
W Medical Certifier Name Title
0 Frances Bollinger, MD
Address
100 Broad Street, Glesn falls, NY
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls, NY 5601
❑Burial Date Cemetery or Crematory
November 23, 2011 Pine View Crematory
❑Entombment Address
[cremation Quaker Rd, Queensbury, NY 12804
ZDate Place Removed
Z❑Removal and/or Held
F and/or Address
GIHold
0 Date Point of
ai❑Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton—Healy Funeral home 01596
Address
407 Bay Rd Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
1 Remains are Shipped, If Other than Above
Address
tr
tt :
Permission is hereby granted to dispose of the human rem s described a ove as in '-d.
Date Issued 11/20/11 Registrar of Vital Statistics _ a,._" A
L5O
(Si
ture � "
District Number / Place gna cture
I certify that the remains of the decedent identified above were disposed of in accordance with this per it on:
LU Date of Disposition uc)V y(i au Place of Disposition .g.s,Vtct.J C,tywc{atoo..
2 (address)
iii
CC (section) ` . (lo number) (grave number)
0
CI Name of Sexton or Pe n in Charge Premises h(ist f J ti,40/4'
2 ( lease print)
) Signature l�J Title C'Q E MYf CO(Z.
// (over)
DOH-1555 (02/2004)