Arcuri, Edward John •
4-7c
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Edward John Arcuri Male
Date of Death Age If Veteran of U.S.Armed Forces,
01/20/2021 86 Years War or Dates
Place of Death Hospital,Institution or
z City,Town or Village Fort Edward Town Street Address Fort Hudson Nursing Center Inc
WW Manner of Death Le
Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
0 Medical Certifier Name Title
Came Miron PA
Address
319 Broadway,Fort Edward Town,New York 12828
Death Certificate Filed District Number Register Number
City,Town or Village Fort Edward 5755 5
Burial Date Cemetery,Crematory or Facility Name
01/21/2021 Pine View Crematory
Ei Entombment Address
EiCremation Queensbury Town,New York
❑Donation
0 ElRemoval Date Place Removed
and/or and/or Held
H Hold Address
0
a. Date Point of
N Li Transportation
p by Common Shipment
Carrier Destination
Disinterment 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
Remains are Shipped,If Other than Above
Address
CC
W
n' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/21/2021 Registrar of Vital Statistics afaltoneygYectronicalTyStgned�
(signature)
District Number 5755 Place Fort Edward, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on•
W Date of Disposition I/2Z Uzi' Place of Disposition 71 ()t"01't1_
2 (address)
W
N
(section) (lot number)` (grave number)
re is
S Name of Sexton or Person in Charge of Pes irt, .. ` )aN4/tilt
Z lease pnn
W Signature /3"— Title 6
DOH-1555(07/t8)p t of 2
Public Health Law Sec. 4145(2b) . 14
1
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License# �: