Fannelli, Michael Allen l,._ . . '2 7O
NEW YORK STATE DEPARTMENT OF H EALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Michael Allen Fannelli
Male
Date of Death Age If Veteran of U.S.Armed Forces,
02/24/2021 60 Years War or Dates
i_ Place of Death Hospital,Institution or
Z City,Town or Village Schenectady Street Address Ellis Hospital
UJ
p Manner of Death ❑X Natural Cause 0 Accident ❑ Homicide ❑Suicide ❑Undetermined 0 Pending
0 Circumstances Investigation
W Medical Certifier Name Title
CI Micheline Ford MD
Address
1101 Nott St,Schenectady,New York 12308
Death Certificate Filed District Number Register Number
City,Town or Village Schenectady 4601 232
oBurial Date Cemetery,Crematory or Facility Name
02/25/2021 Pine View Crematory
0 Entombment Address r
gCremation Queensbury Town,New York
Donation
Z ri Removal Date Place Removed
and/or and/or Held
F.
(A Hold Address
0
CL 1-1 Date Point of
ft) ❑Transportation Shipment
p by Common
Carrier Destination
Date Cemetery Address
0 Disinterment
Date Cemetery Address
0 Reinterment
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
1— Remains are Shipped,If Other than Above
g Address
CC
EL Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 02/25/2021 Registrar of Vital Statistics Sarnanta R,fly*oo(Electronrcall Signea9
(signature)
District Number 4601 Place Schenectady, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: df---
W
Z Date of Disposition 2176 IIIPlace of Disposition
`ll
ddress)
2
W
ID
CC (section)
number) (grave number)
&,‘
0 Name of Sexton or Person in Charge f Premises ( � \. 'µtt
Q lAit
please pInt)^
z I *v<—
W Signature Title
DOH-1555(07/18)pi of 2
Public Health Law Sec. 4145(2b) I 4 5 8 7
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on,burial permit
Official Funeral Directors Reg.or License#