Fitzgerald 111, William Ellsworth t5
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Perimit
Bureau of Vital Records
Name First Middle Last Sex
William Ellsworth Fitzgerald III Male
Date of Death Age If Veteran of U.S.Armed Forces,
01/12/2022 74 Years War or Dates
Place of Death Hospital,Institution or
W City,Town or Village Glens Falls Street Address 20 Elm Street APT 506,Glens Falls,New York 12801
Manner of Death 1=1 Natural Cause 1=1 Accident ❑Homicide ❑Suicide ❑Undetermined El Pending
Circumstances Investigation
WMedical Certifier Name Title
O Kyle Leonard MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 43
ElBurial Date Cemetery,Crematory or Facility Name
01/18/2022 Pine View Crematory
Entombment Address
g Cremation Queensbury Town,New York
▪Donation
Z Removal Date Place Removed
and/or and/or Held
Hold Address
to
0
IL Date Point of
• u Transportation
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
1— Remains are Shipped,If Other than Above
N Address
Q
Alt
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/18/2022 Registrar of Vital Statistics Jlegan.9lroBsn gkctronica*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:
v f Z Date of Disposition I, lei 1 7T Place of Disposition
2 (address)
W
CC (section) n (lot number) (grave number)
O Name of Sexton or Person in Charge of Premises �'
Z
(ease print)
W SignatureZ �� Title
DOH-1555(07/18)p 1 of 2
1 � •
Public Health Law Sec. 4145(2b) 0
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#