Fagnano, Eric I 1
500
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Eric L. _ Fagnano Male
Date of Death Age If Veteran of U.S. Armed Forces,
September 23,2012 65 War or Dates Vietnam
Place of Death Hospital, Institution or
Z City, Town or Village Warrensburg Street Address 92 Schroon River Road
p Manner of Death Natural Cause Accident Homicide X Suicide Undetermined Pending
W Circumstances Investigation
t.)
w Medical Certifier Name Title
C1 William Orluk
Address
Chester Health Center,Chestertown,NY 12817
Death Certificate Filed 1 District Number Register Number
City, Town or Village Warrensburg 5660
❑Burial Date 1 Cemetery or Crematory
September 25,2012 1 Pine View Crematory
❑Entombment Address
❑x Cremation Quaker Rd.,Queensbury,NY 12804
Date Place Removed
Z Removal 1 and/or Held
and/or Address
H Hold
Cl)
O Date I Point of
55 I 'Transportation 1 Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
i
Reinterment Date Cemetery Address
I
Permit Issued to I 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
a Address
CL
tU
Permission is hereby granted to dispose of the huma • s .escribed bove as indicated.
Date Issued 61/ Registrar of Vital Statistic joii
!�
(signature)
District Number 5660 Place Warrensburg
1—
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
to Date of Disposition ci't. j . Place of Disposition Zdaul fv!'iu"--
2 (address)
W
CO
CC (section) gg (lot number (grave number)
pName of Sexton or Pe son in Charge Premises pr (�••- •iwG/f"
Z (please print)
W
Signature Title W M rtag,
(over)
DOH-1555 (02/2004)