Izzo, Michael Joseph NEW YORK STATE DEPARTMENT OF HEALTH /„ 9Cq Bureau of Vital RecordsCOPIArBurial
(
- Tr •
Name First nsit Permit
Michael Joseph Izzo Middle
Date of Death Last
07/28/2022 If Veteran of U.S.Armed Forces, EMI
Place of Death War or Dates
City,Town or Village Hospital,Institution or
Manner of Death Queensbury Town Street Address 47 Queen MaryDrive,
Natural Cause ❑AccidentEj Queensbury Town,New York 12804
Homicide OSuicide ❑Undetermined
Medical Certifier Name Pending
Circumstances
Aqeel Gillani Title Investigation
Address MD
100 Park St,Glens Falls,New York 12801
Death Certificate Filed
Town Of Queensbury District Number
City,Town or Village
II Burial Date 5657 Register Number
Cemetery,Crematory or Facilit Name 113
II Entombment
07/29/2022 Pine View Crematory y
Address
Cremation Queensbury,New York
■Donation
Z❑Removal Date
and/or Place Removed
F.: and/or Held
N Hold Address
0
a_ Date
N❑Transportation Point of
IO by Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
Date Cemetery Address
III Reinterment
Permit Issued to
Name of Funeral Home Regan Denny Stafford Funeral Home Registration Number
Address 01443
53 Quaker Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
1.. Remains are Shipped,If Other than Above
a Address
CC
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 07/29/2022 Registrar of Vital Statistics Caroliine.7fi(egarde Bar6er(EfectronicaffySigned)
(signature)
District Number 5657 Place Town Of Queensbury
tetttfy that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition I I1 I zt Place of Disposition
(address)
' (section) /(lot number)
(grave number)
re, Name of Sexton or Person in Charge of Pi. ises It
/+.{
/pleas:'print/
Signature _ Title C.4
DOH•15551011101 p toi 2
1
1 Public Health Law Sec. 4145(2b)
1
Receipt
1
Human remains of delivered on , 20
1
II
Pine View Cemetery Representing the funeral home named on burial permit
i Official Funeral Directors Reg.or License#