Fusco, Cornelia Alice - # izo/
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NEWYORKSTATEDEPARTMENTOFHEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Cornelia Alice Fusco Female
Date of Death Age If Veteran of U.S.Armed Forces,
11/11/2020 78 Years War or Dates
H Place of Death Hospital,Institution or
Z City,Town or Village Queensbury Town Street Address 67 Cedar Court,Queensbury Town,New York 12804
`p Manner of Death ❑X Natural Cause ❑Accident ❑Homicide E=1 Suicide ❑Undetermined ❑Pending
0 Circumstances Investigation
GMedical Certifier Name Title
Suzanne Blood MD
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed District Number Register Number
City,Town or Village Queensbury 5657 205
❑Burial Date Cemetery,Crematory or Facility Name
11/12/2020 Pine View Crematory
Entombment Address
aCremation Queensbury,New York
❑Donation
Removal Date Place Removed
and/or and/or Held
N Hold Address
0
d Date Point of
fA ❑Transportation
by Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped,If Other than Above
a Address
Q
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11/12/2020 Registrar of Vital Statistics Caroliinexkligard Bader(E/ctronicaf Signed)
(signature)
District Number 5657 Place Queensbury, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
IF-
W Date of Disposition ///c/249/j Place of Disposition ,je_ 12,64) C Jiyekfr,
2 (add s)
W
CO -
CC (section); (tot numbe (grave number)
CName of Sexton or Person in Cha e of Premis /5�4jj�o.+ �� f c
Z (please print)
W Signature f!! Title CyleSecirskr
DOH-1555(07/18)p t of 2
•
-Public Health Law Sec. 4145(2b) .s•
�1419
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#