Quagliaroli Jr., Peter Joseph NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Peter Joseph Quagliaroli Jr. Male
Date of Death Age If Veteran of U.S.Armed Forces,
01/03/2022 57 Years War or Dates
Place of Death Hospital,Institution or
WCity,Town or Village Glens Falls Street Address Glens Falls Hospital
p Manner of Death 0 Natural Cause ElAccident ❑ Homicide ❑Suicide ❑Undetermined Pending
W V Circumstances Investigation
W Medical Certifier Name Title
Sean Bain MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 1
❑Burial Date Cemetery,Crematory or Facility Name
01/05/2022 Pine View Crematory
❑Entombment Address
0 Cremation Queensbury Town,New York
0 Donation
z ❑Removal Date Place Removed
and/or and/or Held
N Hold Address
0
la Date Point of
U) ❑Transportation Shipment
p by Common
Carrier Destination
El 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
a Address
CC
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/05/2022 Registrar of Vital Statistics Megan (E/ctronicall Signed)
(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:
IH �
WDate of Disposition I/(e ILZ. Place of Disposition �1 .4.4
2 (address)
W
CC
(section) (lot number) (grave number)
0 Name of Sexton or Person in Charge of Premis
(ple a print)
W Signature Title r1' Y„11Pr
DOH-1555(07/18)p t of 2
51
Public Health Law Sec. 4145(2b)
Receipt
1 Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License# '