Cavicchioli, Alfayo Phillip Iz?1
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Alfayo Philip Cavicchioli Male
Date of Death Age If Veteran of U.S.Armed Forces,
12/01/2020 99 Years War or Dates 1942-1945
Place of Death Hospital,Institution or
Z▪ City,Town or Village Glens Falls Street Address Glens Falls Hospital
p Manner of Death I Natural Cause Accident 1=1Homicide ❑Suicide Undetermined Pending
W Circumstances Investigation
W Medical Certifier Name Title
G Mary Stein NP
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 549
ElBurial Date Cemetery,Crematory or Facility Name
12/04/2020 Pine View Crematory
ElEntombment Address
0 Cremation Queensbury Town,New York
EiDonation
Z Removal Date Place Removed
and/or and/or Held
F- Hold Address
0
d Date Point of
VI LI Transportation
p by Common Shipment
Carrier Destination
ElDisinterment Date Cemetery Address
Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D Baker Funeral Home 01130
Address
11 Lafayette St,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
F— Remains are Shipped,If Other than Above
Address
EC
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/04/2020 Registrar of Vital Statistics Rp&ertfln�rew Curtis gkctroniat16,5gned)
(signature)
District Number 5601 Place Glens Falls, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
~
Z Al o Date of Disposition �Z (TO Place of Disposition t'��a,.
W
2 (address)
W
(section) (lot n(Ar. rpL
ber) (grave number)
GName of Sexton or Person in Charge of Pr ises SH
Z
W Signature Title l Vfi tta
DOH-1555(07/18)p t of 2
Public Health Law Sec. 4145(2b) 014264
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#