Fonda, Pierre NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Pierre Fonda Male
Date of Death Age If Veteran of U.S.Armed Forces,
01/01/2021 66 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Northumberland Town Street Address 326 Duncan Road,Northumberland Town,New York 12831
W
p Manner of Death ❑X Natural Cause ❑Accident Homicide ❑Suicide ❑Undetermined ❑Pending
0 Circumstances Investigation
W Medical Certifier Name Title
O Paul Gebhard MD
Address
1 West Avenue,Saratoga Springs,New York 12866
Death Certificate Filed District Number Register Number
City,Town or Village Northumberland Town 4563 1
❑Burial Date Cemetery,Crematory or Facility Name
01/05/2021 Pine View Crematory
❑Entombment Address
X❑Cremation Queensbury Town,New York
Donation
ZZ Removal Date Place Removed
- and/or and/or Held
~N Hold Address
0
▪ 1-1 Date Point of
(/) ❑Transportation
p by Common Shipment
Carrier Destination
El
Disinterment
Date Cemetery Address
Reinterment
Date Cemetery Address
- Permit Issued to Registration Number
Name of Funeral Home Compassionate Funeral Care Inc 00364
Address
402 Maple Ave,Saratoga Springs,New York 12866
Name of Funeral Firm Making Disposition or to Whom
F Remains are Shipped,If Other than Above
Address
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/05/2021 Registrar of Vital Statistics Denise D.ffurplty(EYectrontiaIT Stgnerl)
(signature)
District Number 4563 Place Northumberland Town, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition 1417( Place of Disposition
11.1 (address)
W
CC N (section) (lot nu r) r (grave number)
0 Name of Sexton or Person in Charge of miser °y R 't`t t
(please print)
roic frr
lL 1-`71 Title
Signature
DOH-1555(o7/18)p i of 2
Public Health Law Sec. 4145(2b) ` 014 38 2
Receipt
Human remains of delivered on ` , 20
/ ,.
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License# ` '