Pelosi, Ferdinand A. NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Ferdinand A.Pelosi Male
Date of Death Age If Veteran of U.S.Armed Forces,
04/03/2021 95 Years War or Dates 1943-1946
Place of Death Hospital,Institution or
Z City,Town or Village Queensbury Town Street Address 39 Longview Drive APT 179,Queensbury Town,New York 12804
p Manner of Death g Natural Cause El Accident Homicide I]Suicide ❑Undetermined EI Pending
W Circumstances Investigation
Q Medical Certifier Name Title
Michelle Ryan NP
Address
2554 Route 9,Malta Town,New York 12020
Death Certificate Filed District Number Register Number
City,Town or Village Queensbury 5657 87
0 Burial Date Cemetery,Crematory or Facility Name
04/07/2021 Pine View Crematory
❑Entombment Address
ElCremation Queensbury Town,New York
12 Donation
OZ El Removal Date Place Removed
and/or and/or Held
}- Hold Address
0
Q. Date Point of
fl) 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
i.. Remains are Shipped,If Other than Above
g Address
fX
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 04/06/2021 Registrar of Vital Statistics Carolinexldegar. Barb.er(Electronicallj ISOne4
(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:
Z Date of Disposition L'/1 Z Place of Disposition
ILI
2 (address)
W
N
Q (section) number) (grave number)
g Name of Sexton or Person in Charge of Pre s (lot
^i
Z (pleas rint)
IL Signature Title Ci1"�1
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) 014700
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#