Fugaazy, Jeffrey Frank r : E\NS)NEW YORKSTATE DEPARTMENT OF HEALTH
Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Jeffrey Frank Fugazy Male
Date of Death Age If Veteran of U.S.Armed Forces,
10/04/2022 56 Years War or Dates
Place of Death Hospital,Institution or
2 City,Town or Village Glens Falls Street Address Glens Falls Hospital
IIJ
Manner of Death Undetermined Pendin
W Natural Cause Accident Homicide Suicide g
Circumstances Investigation
W Medical Certifier Name Title
G Gamal Khalifa MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed City Of Glens Falls District Number Register Number
City,Town or Village 5601 509
Burial Date Cemetery,Crematory or Facility Name
10/06/2022 Pine View Crematorium
Entombment Address
Cremation Queensbury Town,New York
Donation
Q II Removal Date Place Removed
and/or and/or Held
N Hold Address
0
O. Date Point of
(I)❑Transportation
p by Common Shipment
Carrier Destination
o
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
Remains are Shipped,If Other than Above
2 Address
IX
IW
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 10/06/2022 Registrar of Vital Statistics MeganWofin(ECectronicaItySigned)
(signature)
District Number 5601 Place City Of Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z �
Date of Disposition 10�(��tZ Place of Disposition �1.4 V
2 (address)
W
N°` dr,4/section) L_
(lot number) (grave number)
Name of Sexton or Person in Charge Premises
Z /�ase print)
W Signature Title ` ' //V
DOH-1555(07/18)p t of 2
Public Health Law Sec. 4145(2b)
Receipt
1
1
Human remains of delivered on , 20
1
I
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#