Pezzulo, Vincent NEW YORK STATE DEPARTMENT OF HEALTH ;
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Vincent Joseph Pezzulo Male
Date of Death Age If Veteran of U.S. Armed Forces,
11/26/2014 73 years War or Dates National Guard _
i Place of Death Hospital, Institution or
Z City, TowXX (X[ilj�gXXX Glens Falls Street Address Park St Glens Falls, N Y 12801
WManner of Death biatural Cause 0 Accident 0 Homicide Ei Suicide El Undetermined El Pending
C.) Circumstances Investigation
w Medical Certifier Name Title
41 Randall Burchell Md
Address
Rte#50 Saratoga Springs, N Y
Death Certificate Filed District Number Register Number
City, TovAXXX/iDOXJXXX Glens Falls 5601 550
sii<❑Burial Date Cemetery or Crematory
12/02/2014 Pine View Cemetery
❑Entombment Address
,JOremation Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
C ❑F_ and/or -Address
Hold
0 Date Point of
1114 Q Transportation Shipment
a by Common Destination
Carrier
❑Disinterment Date Cemetery Address
Li Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Road Queensbury, NY
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
a Address
ft
to
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/02/2014 Registrar of Vital Statistics W CI,,�y`Q, .),_)
(signature
District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2
t1 Date of Disposition i L(3114 Place of Disposition Vfe.J Clot,
iiII
CA
CC (section) /,�// (lot numb )
(grave number)
Name of Sexton or Person in Charge of Premises J(ri 9�Q L v�" '
9 Ij(please print)
Signature III /+ 'G//�i - Title 11A:Ii'PtThlQ
(over)
DOH-1555 (02/2004)