Zita, Ronald Richard s11
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records •
Name First Middle Last Sex
Ronald Richard Zita Male
Date of Death Age If Veteran of U.S.Armed Forces,
01/12/2022 61 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
W
`p Manner of Death ❑k Natural Cause El Accident ❑Homicide Suicide ❑Undetermined Pending
V Circumstances Investigation
0ILI Medical Certifier Name Title
Mathew Varughese DO
Address
100 Park St,Glens Falls,New York 12801
Death Certificate.Filed District Number Register Number
City,Town or Village Glens Falls 5601 37
Burial Date Cemetery,Crematory or Facility Name
01/18/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
❑Donation
Removal Date Place Removed
and/or and/or Held
Hold Address
CO
0
O. 1-1 Date Point of
co 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
2 Address
CC
uJ
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/14/2022 Registrar of Vital Statistics Megan glroCrn(IYectronicaf 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:
F— Al.—Date of Disposition 1120 172 Place of Disposition <Fn.A l ate
W
(address)
W
N CC (section) plot number) (grave number)
el Name of Sexton or Person in Charge of Premis i$ h Snni tt
Z / /ease print/ �?
W Signature L%�` Title t 'i�INH'rtC'
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b)
1 Receipt
1
1
IHuman remains of delivered on i , , 20
1
1
t
Pine View Cemetery Representing the funeral home named on burial permit
1 Official Funeral Directors Reg.or License#
V -