Gezzi, Adorno NEW YORK STATE DEPARTMENT OF HEALTH " A (s tip
Vital Records Section Burial - Transit Permit
;" Name First Middle Last Sex
Adorno Orlando Gezzi Male
ax Date of Death Age If Veteran of U.S. Armed Forces,
November 28,2012 89 War or Dates WWII
• f=, Place of Death Hospital, Institution or
C• ity, Town or Village Johnsburg Street Address 46 Fairview Avenue
Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
At Circumstances Investigation
ig M• edical Certifier Name Title
Daniel Sooriabalan MD
Address
• HHHIN
1 Death Certificate Filed District Number Register Number
a City, Town or Village Johnsburg 5655 'vU
❑Burial Date Cemetery or Crematory
❑Entombment November 28,2012 Pine View Crematory
Address
❑x Cremation 21 Quaker Rd., Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
N Hold
N
O 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
3• 809 Main Street,Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
a:,; Remains are Shipped, If Other than Above
Address
t✓
. Permission is hereby granted to dispose of the human rem ins described ve as indicated.
Date Issued // oq e&oil Registrar of Vital Statistics e
a.....,,_
„.
/ (signature)
✓ District Number 5655 Place Johnsburg
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
w Date of Disposition /// J17._ Place of Disposition �,Nti/` C �
um (address
cn
O (section) ✓ (lot number) (grave number)
Op Name of Sexton Per on i arge of Premises �j-74 ley, J
Z �/ (please print)
W Signature G{- Title effibilk,d-be____ A` .
(over)
DOH-1555 (02/2004)