Missita, George Leon 111 w.
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(07T
NEWYORKSTATEDEPARTMENTOFHEALTH r '
Bureau of Vital Records Burial - Transit Permit
Name First Middle Last Sex
George Leon Missita III Male
Date of Death Age I If Veteran of U.S.Armed Forces,
08/22/2022 65 Years ) War or Dates
H Place of Death Hospital,Institution or
ILI
Z City,Town or Village Albany Street Address Albany Medical Center Hospital
p Manner of Death EINatural Cause ❑Accident 0 Homicide Suicide Undetermined Pending
W
V Circumstances Investigation
0 Medical Certifier Name Title
Ingrid Bedinotti PA
Address
43 New Scotland Ave,Albany,New York 12208
Death Certificate Filed City Of Albany District Number Register Number
City,Town or Village 0101 1961
Burial Date Cemetery,Crematory or Facility Name
® 08/23/2022 Pine View Crematorium
Entombment Address
Cremation Queensbury Town,New York
Donation
goRemoval Date Place Removed
H and/or and/or Held
N Hold Address
0
a Date Point of
N❑Transportation
G by Common Shipment
Carrier Destination
ODisinterment 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- Remains are Shipped,If Other than Above
a Address
OC
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 08/23/2022 Registrar of Vital Statistics 'Daniel7eS C illespie(ECectronicallySigned)
(signature)
District Number 0101 Place City Of Albany
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I—
Z Date of Disposition 'C3,�r�
•.2,-/ ZOLLPlace of Disposition .Poi w ,e+.J G/�..,,yp i,-/
W (address)
CO
LCName (section) % lot number) (grave number)
of Sexton or Person' arge Premises k-11 e. 1 e-t rt. 4, .,L
Z (please print) �"
W Signature Title r%/G.-0- _7 0t / Ope-a,Ilr.-
DOH-1555(07/18)p 10 2 / �/
1. 1 .
Public Health Law Sec. 4145(2b)
1 Receipt
I
I Human remains of delivered on ,
1 20 -- .
Pine View Cemetery Representing the funeral home named pn,burial permit
Official Funeral Directors Reg.or License#