Bannon, Fredrick Oliver NEW YORK STATE DEPARTMENT OF HEALTH C.,:i.. ti 3q
Bureau of Vital Records Burial - Transit Permit
Name First Middle Last Sex
Frederick Oliver Bannon Male
Date of Death Age If Veteran of U.S.Armed Forces,
04/08/2022 62 Years War or Dates
1.., Place of Death Hospital,Institution or
WCity,Town or Village Fort Ann Town Street Address 1193 Farley Road,Fort Ann Town,New York 12839
p Manner of Death 0 Natural Cause Accident 0 Homicide 0Suicide Undetermined riPending
W C.) Circumstances Investigation
ILI Medical Certifier Name Title
CI Anthony Petracca MD
Address
3 Irongate Center,Glens Falls,New York 12801
Death Certificate Filed Town Of Fort Ann District Number Register Number
City,Town or Village 5754 9
Burial Date Cemetery,Crematory or Facility Name
04/12/2022 Pine View Crematorium
Entombment Address
Cremation Queensbury Town,New York
Donation
OZ❑Removal Date Place Removed
and/or and/or Held
F— Hold Address
0
O. Date Point of
(/)❑Transportation
15 by Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home Inc 00281
Address
68 Main Street,P.O.Box 67,Hudson Falls,New York 12839
Name of Funeral Firm Making Disposition or to Whom
1... are Shipped,If Other than Above
2 Address
Q
W
0. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 04/11/2022 Registrar of Vital Statistics Barbara 1 Winched(ECectronica1TySigned)
(signature)
District Number 5754 Place Town Of Fort Ann
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I—
WDate of Disposition 9--/3.-7p2Z Place of Disposition F/hPi V,e' J C ''C,rnt,4a
2 (address)/
W
CC (section) (lot number) (grave number)
SName of Sexton or Person in Charge of Premises — 31,1,,1 r 444 G441c4/
Z (please print)
W Signature Title G--t'm t4./dsy ci�.It„j��
DOH-1555(07/18)p 1 of /
$
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#