Fragassi, Nicholas 4A-1Ci
�NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Nicholas A. Fragassi Male
Date of Death Age If Veteran of U.S. Armed Forces,
August 21, 2012 93 War or Dates n/a
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death ❑X Natural Cause n Accident ❑Homicide n Suicide ❑Undetermined n Pending
vt Circumstances Investigation
W Medical Certifier Name Title
f Michael Fuller,MD
Address
Glens Falls,NY
Death Certificate Filed District Number Register
City, Town or Village Glens Falls,NY 5601
❑Burial Date Cemetery or Crematory
❑Entombment August 23,2012 Pine View Crematory
Address
®Cremation Quaker Road, Queensbury,NY 12804
Date Place Removed
Z 1-1 Removal and/or Held
and/or Address
E Hold
N
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
1 Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Road,Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
14
Permission is hereby granted to dispose of the human remains descr' ed abo
as,• ii ated.
Date Issued , -231.40/-2—Registrar of Vital Statistics j ,rc '��
(signature)
District Number 5601 Place Glens Falls,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z ,)
LU Date of Disposition Place of Disposition „.i.Vttt,/ Cr-itif1u�,
W (address)
CO
re (section) 3())
(tot,number) ( (grave number)
QName of Sexton or Person in Charge o Premises emilt'
Z (p ase print)
ILI
Signature A � Title C.LE h -p(Z
(over)
DOH-1555(02/2004)