DiCicco, Frank Dominic NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Frank Dominic Di Cicco Male
Date of Death Age If Veteran of U.S.Armed Forces,
05/12/2023 75 Years War or Dates
Place of Death Hospital,Institution or
W City,Town or Village Hudson Falls Village Street Address 38 Pearl Street,Hudson Falls Village, New York 12839
p Manner of Death ❑X Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
WMedical Certifier Name Title
William Parker MD
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed Village Of Hudson Falls District Number Register Number
City,Town or Village 5726 12
Burial Date Cemetery,Crematory or Facility Name
05/23/2023 Pine View Cemetery
Entombment Address
Cremation Queensbury Town,New York
Donation
g❑Removal Date Place Removed
and/or and/or Held
N Hold Address
0
O. Date Point of
(f) 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
a Address
CC
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 05/16/2023 Registrar of Vital Statistics Cynthia A'Bardin(ECectronica1CySigned)
(signature)
District Number 5726 Place Village Of Hudson Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 508•a-3 Place of Disposition 6)I nAiC iSbj(,
2 (address)CC
(section) lot number/ (grave number)
/g Name of Sexton or Person in Charge of Premises ' env\t C �
(please print)
W Signature Title SUyP(Z
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b)
012982
Receipt
Human remains of delivered on ` -t ', 20 y-y
A
r / ;
Pink View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License# ! ' '7
DICICCO /
NAME Frank Dominic DiCic ge`75
Lot Owner: Maria DiCicco
Lot# Seneca 21 -L Grave# 1
Case: Concrete
Died: 5. 1 2.2 3 Interred: 5.2 8.2 3
Funeral Home: Carleton FH
Cemetery: Pine View
DICICCO
Owner
Maria DiCicco
Address Plot
38 Pearl St. Hudson Falls, NY 12839 Seneca
Phone # Lot #
518-744-5869 21 -L
Deed # Date
4383 5.12.23
Cost Foundation Y - N
$800.00
Location
North-Lampkins
East-Woods
West-Edwoods
South-Hermance
Remarks
I ACKNOWLEDGE THE RECEIPT OF THE RULES AND REGULATIONS OF THE
PINE VIEW CEMETERY:
SIGNATURE: ctAA:-a _ I CA DATE: 5• I2. 23
SIGNATURE: DATE:
Record of Interments
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2 7
3 8
4 9
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