Vetrano, Michael Jr. NEW YORKSTATE DEPARTMENT OF HEALTH . k
Bureau of Vital Records Burial - Transit Permit
Name First Middle Last Sex
Michael Vetrano Jr. Male
Date of Death Age If Veteran of U.S.Armed Forces,
12/10/2022 42 Years War or Dates
f,. Place of Death Hospital,Institution or
Z City,Town or Village Fort Ann Town Street Address 11739 State Route 22, Fort Ann Town, New York 12827
ILI
'p Manner of Death ❑Natural Cause Accident ElHomicide Suicide Undetermined El Pending
Circumstances Investigation
W Medical Certifier Name Title
C Wesley Perry Coroner
Address
415 Lower Main Street,Hudson Falls Village,New York 12839
Death Certificate Filed Town Of Fort Ann District Number Register Number
City,Town or Village 5754 26
Burial Date Cemetery,Crematory or Facility Name
12/16/2022 Pine View Crematorium
Entombment Address
Cremation Queensbury Town,New York
DDonation
o❑Removal Date Place Removed
and/or and/or Held
F-N Hold Address
0
O. Date Point of
t/1 Transportation
p by Common Shipment
Carrier Destination
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
ILLI
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/16/2022 Registrar of Vital Statistics Jennifergackson(ECectronicalty Signed)
(signature)
District Number 5754 Place Town Of Fort Ann
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition IZ 12 t. Place of DispositionDJ
(address)
W
N
OC (section) /� (lot number) sivvo (grave number)
0 Name of Sexton or Person in Charge of Premises l/ ^
Z (p ase print)
W 4
Signature - Title (C6I l�7+
g
DOH-1555(07/18)p 1 of 2
F " . ..;� 5.. R s'
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#