Picciolo, Michael W 1.,„(L..F)
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records ''`
Name First Middle Last Sex
Michael W.Picciolo Male
Date of Death Age If Veteran of U.S.Armed Forces,
08/26/2022 65 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Warrensburg Town Street Address 6 Oak Street,Warrensburg Town,New York 12885
111
`p Manner of Death II Natural Cause Accident ❑Homicide Suicide Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
0 Tanya Finch NP
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed Town Of Warrensburg District Number Register Number
City,Town or Village 5660 14
Burial Date Cemetery,Crematory or Facility Name
08/29/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
o Removal Date Place Removed
and/or and/or Held
H
N Hold Address
0
a Date Point of
U) Transportation
p by Common Shipment
Carrier Destination
ODisinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Alexander Baker Funeral Home 00037
Address
3809 Main St,Warrensburg,New York 12885
Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped,If Other than Above
g Address
R
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 08/29/2022 Registrar of Vital Statistics cPame(a gv[LCoydicECectronicalty Signed)
(signature)
District Number 5660 Place Town Of Warrensburg
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
IF-
Z Date of Disposition fei Z$tit Place of Disposition
W (address)
W
CC
N
(section) (lot number) (grave number/
SName of Sexton or Person in Charge of P mises
Z ^ (pi se—print)
W Signature ( Title CarrOVIC
DOH-1555(07/18)p t of 2
1 e
Public Health Law Sec. 4145(2b)
Receipt
0 :1, 619 6
1 „ A
Human remains of : ' delivered on '
,
, 20
. ,
,.... -
1, _pine View Cemetery Representing the funeral home named on,burjal permit
I -' Official
Funeral Directors Reg.or License# ' - ' .'