Caselnova, Christopher Albert LL.F„)
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NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Christopher Albert Caselnova Male
Date of Death Age If Veteran of U.S.Armed Forces,
01/04/2022 57 Years War or Dates
H Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address 21 Hartford Avenue F,Glens Falls,New York 12801
IIJ
0 Manner of Death ❑X Natural Cause ❑Accident ❑ Homicide ❑Suicide ❑Undetermined ❑Pending
W C.) Circumstances Investigation
Ui Medical Certifier Name Title
0 Paul Bachman MD
Address
3767 Main Street,Warrensburg Town,New York 12885
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 23
EiBurial Date Cemetery,Crematory or Facility Name
01/10/2022 Pine View Crematory
❑Entombment Address
K❑Cremation Queensbury Town,New York
❑Donation
Removal Date Place Removed
and/or and/or Held
H Hold Address
N
0
O. Date Point of
CO Li Transportation
CI 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
F,. Remains are Shipped,If Other than Above
a Address
CC
W
4' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/10/2022 Registrar of Vital Statistics Megan.9lroln(Electronicall:y 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:
Z Date of Disposition ( 'IL ill_ Place of Disposition c7:-1 Cj�L_
w (address)
W
Q (section) /1 n11otnu r/ c (grave number)
0 Name of Sexton or Person in Charge of Premises i'ujt
Zi
/p!e e print/
W Signature ..,_ Title (1Z M IV..
DOH-1555(o7/18)p 1 of 2
0" F 79
Public Health Law Sec. 4145(2b)
1 Receipt
.
a'‘
i
Human remains of - delivered on , 20
0
Pine View Cemetery Representing the funeral home named on burial permit
x
Official Funeral Directors Reg.or License# '