Mercurio, Joseph NEW YORK STATE DEPARTMENT OF HEALTH # 5 ) 6
Vital Records Section F ) Burial - Transit Permit
Name First Middle Last Sex
Joseph Michael Mercurio Male
Date of Death Age If Veteran of U.S. Armed Forces,
September 30, 2012 68 War or Dates
i— Place of Death Hospital, Institution or
WCity, Town or Village Fort Edward Street Address 278 Broadway
WManner of Death 0 Natural Cause Accident Homicide 0 Suicide Undetermined Pending
Ci
Circumstances Investigation
W' Medical Certifier Name Title
L
Graham Atkins, Dr.
Address
West Mountain Primary Care Queensbury, NY 12804
Death Certificate Filed District Number Regis tuber
City, Town or Village ,5`"7S_C
0 Burial Date Cemetery or Crematory
October 2, 2012 Pine Vew Crematorium
0 Entombment Address
®Crernation , Queensbury,NY 12804
Date Place Removed
z El Removal and/or Held
and/or Address
p Hold
Date
O Point of
u,,0 Transportation Shipment
CO by Common Destination
Ei Carrier
Disinterment Date Cemetery Address
0 Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
E' Remains are Shipped, If Other than Above
2 Address
IX
Wii
iL Permission is her granted to dispose of the human ins described abov as indicated.
Date Issued/l)/ ��— Registrar of Vital Statisti
(signature
District Number )7 Place%4✓j 4 c (3'J/- EC:VC-c/a...4
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I~-ILI Date of Disposition to/3)12 Place of Disposition .20r+%) iry►rtrn,_
W (address)
co
ce (section) A (lot number) c (grave number)
ci Name of Sexton or Per on in Charge o remises fi Q
Z` ( lease print)
W''
Signature Title Cti .MPET012
(over)
DOH-1555 (02/2004)