Faggiano, Josephine NEW YORK STATE DEPARTMENT OF HEALTH 4 497
Vital Records Section 4 Burial - Transit Permit
Name First 'Middle Last Sex
Josephine F. Faggiano Female
Date of Death Age If Veteran of U.S. Armed Forces,
September 6,2011 82 War or Dates
E. Place of Death ' Spital, Institution or
Z. City, Town or Village Chester Street Address 148 White Schoolhouse Road
Iii
in Manner of Death
X Natural Cause I I Accident Ej Homicide Suicide Undetermined Pending
W Circumstances Investigation
`W Medical Certifier Name Title
0 Paul Bachman
Address
IIHHN,Warrensburg,NY 12885
Death Certificate Filed District Number Register Number
City, Town or Village Chestertown 5652 \ L9
❑Burial Date Cemetery or Crematory
II
Entombment September 7,2011 Pine View Crematory
Address
❑x Cremation Quaker Rd.,Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
0 and/or Address
H Hold
U)
0 Date Point of
N Transportation - Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Alexander-Baker Funeral Home 00035
Address
3809 Main Street, Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
1-; Remains are Shipped, If Other than Above
Address
Ce
tit
O.
Permission is hereby granted to dispose of the hum remains described ab a indicated.
Date Issued \- .�g� ' S
��� Registrar of Vital Sta ' • h �,
(signatur
District Number 5652 Place Chestertown
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z /�
iti Date of Disposition h k Itt Place of Disposition i i l nnCt06P -
W (address)
U)
LY
(section) 4 (lot number (grave number)
Q Name of Sexton or Person in Charge f Premises c,A „,..itt _
Z (please print)
tu
Signature 4 Title (kb r iotL
(over)
DOH-1555 (02/2004)