Fusco, Peter Michael 1I 2IS
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Peter Michael Fusco Male
Date of Death Age If Veteran of U.S.Armed Forces,
03/05/2022 27 Years War or Dates
H Place of Death Hospital,Institution or
W City,Town or Village Queensbury Town Street Address Burke Drive 212C,Queensbury Town, New York 12804
p• Manner of Death Natural Cause Accident 0 Homicide Suicide Undetermined a Pending
Circumstances Investigation
W Medical Certifier Name Title
O Michael Sikirica MD
Address
50 Broad Street,Waterford Town,New York 12188
Death Certificate Filed Town Of Queensbury District Number Register Number
City,Town or Village 5657 48
HBurial Date Cemetery,Crematory or Facility Name
03/08/2022 Pineview Crematorium
Entombment Address
Cremation Queensbury Town,New York
Donation
0 Removal Date Place Removed
LI and/or and/or Held
H Hold Address
N ,
0
C. Date Point of
(/)OTransportation Shipment
p by Common
Carrier Destination
Date Cemetery Address
Disinterment
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Radloff Funeral Home Inc 01425
Address
136 Warren St,Glens Falls,New York 12801
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped,If Other than Above
N Address
IX
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 03/08/2022 Registrar of Vital Statistics Caroline Hildegarde Barber(Electronically Signed)
(signature)
District Number 5657 Place Town Of Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
~ t��/-0
Z Date of Disposition 3�� ' x� Place of Disposition ti-✓ �,/buf�LV--
2 address)
W
Ncr ,(section) 4 !lot number) (grave number)
CName of Sexton or Person in Charge f Premises �'t �':4�11�
Z (p1 se print) f
W TerZ
Signature �" Title G�6�"�
g
DOH-1555(07/18)p 1of 2
Ji 551a: 9
Public Health Law Sec. 4145(2b) .."•
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#