Pitcheralle, Samuel Joseph • 1-rn
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Samuel Joseph Pitcheralle Male
Date of Death Age If Veteran of U.S.Armed Forces,
12/04/2020 66 Years War or Dates
Place of Death Hospital,Institution or
WCity,Town or Village Queensbury Town Street Address 16 Algonquin Dr,Queensbury Town, New York 12804
p Manner of Death ❑X Natural Cause El Accident 1=1 Homicide El Suicide �Undetermined Pending
v Circumstances Investigation
W Medical Certifier Name Title
CI Thomas Portuese MD
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed District Number Register Number
City,Town or Village Queensbury 5657 217
Burial Date Cemetery,Crematory or Facility Name
12/07/2020 Pine View Crematory
❑Entombment Address
K❑Cremation Queensbury,New York
ElDonation
Z 1=1Removal Date Place Removed
and/or and/or Held
Hold Address
NQ
Date Point of
co Li Transportation Shipment
by Common
Carrier Destination
El Disinterment
Date Cemetery Address
1=1Reinterment 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
Remains are Shipped,If Other than Above
2 Address
CC
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/06/2020 Registrar of Vital Statistics CarolneYaligarie Barber(EYectronica4r Signe42
(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:
Date of Disposition I Z 17 I 70 Place of Disposition ) �--
111 /
W
EC (section) (lot number (grave number)
gName of Sexton or Person in Charge of ises ��n f
(plibase print)W /Signature �' Title i '144$4• 1t
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) ) 14 2. t__r.• �
Receipt
Human remains of _ delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#