Fayette, Timothy Paul 551
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First I Middle Last Sex
Timothy Paul Fayette Male
Date of Death Age If Veteran of U.S.Armed Forces,
07/02/2021 - 65 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address 28A Orville Street,Glens Falls,New York 12801
Manner of Death 0 Natural Cause El Accident El Homicide ❑Suicide Undetermined Pending
W Circumstances Investigation
Medical Certifier Name Title
0 Anthony Petracca MD
Address
3 Irongate Center,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 276
Burial Date Cemetery,Crematory or Facility Name
07/07/2021 Pine View Crematory
ElEntombment Address
X❑Cremation Queensbury Town,New York
Donation
6 Ei Removal Date Place Removed
and/or and/or Held
H N Hold Address
0
Ua) Transportation Date Point of
p by Common Shipment
Carrier Destination
11
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
F. Remains are Shipped,If Other than Above
Address
Q
W
a. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 07/07/2021 Registrar of Vital Statistics Ro6ertylnarrewCurtzr(EI ctronicaffySigned)
(signature)
District Number 5601 Place Glens Falls, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 7/p 112 r Place of Disposition p,,A)e V e1 ) PJ 44c,r-s
2 (address)
W
IE N (section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises/
AVIM o�� �� tdcej
Z (please print)
W ----
Signature C ' Title 90-?'c
DOH-1555(o7/18)p i of 2
I
1 Public Health Law Sec. 4145(2b) 0 ._4 927
Receipt
Human remains of delivered on , 20
'
/ ''`c 1 /. ,' r/, q,Pine View CemeteryRepresentin//-is.,
the funeral home named on burial permit
Official Funeral Directors Reg.or License#
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