Plazola, Marco Antonio 41)NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit 7
Bureau of Vital Records
Name First Middle Last Sex
Marco Antonio Plazola Male
Date of Death Age If Veteran of U.S.Armed Forces,
05/09/2022 44 Years War or Dates
F. Place of Death Hospital,Institution or
Z City,Town or Village Queensbury Town Street Address 12 Goldfinch Road,Queensbury Town,New York 12804
p Manner of Death E1 Natural Cause Accident Homicide Suicide Undetermined Pending
✓ I—ICircumstances Investigation
GMedical Certifier Name Title
Christopher Mason DO
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed Town Of Queensbury District Number Register Number
City,Town or Village 5657 85
Burial Date Cemetery,Crematory or Facility Name
R05/11/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
DDonation
0❑Removal Date Place Removed
and/or and/or Held
H Hold Address
N
0
O. Date Point of
(I)ElTransportation
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
N Address
CC
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 05/11/2022 Registrar of Vital Statistics Caroline gliffegarie Barber(ECectronicalTySigned)
(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:
WDate of Disposition S�12 ZZ Place of Disposition rti
2 (address)
W
Cl)CC (section) (lot number) (grave number)
GName of Sexton or Person in Charge of remises o� Ste,/�
Z / (p! se print)
W Signature Title Cr�'W
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home-nained on burial permit
Official Funeral Directors Reg.or License#