Scallero, Nicholas — "- k
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Nicholas F. Scallero male
Date of Death I Age If Veteran of U.S. Armed Forces,
03/10/06- i 83 War or Dates WWII
Place of Death Hospital, Institution or
iN, XAMC/XliitvitIMPX Glens Falls Street Address Glens Falls Hospital
Manner of Death Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined El Pending
U4 Circumstances Investigation
ill Medical Certifier Name Title
1 Amy Hogan-Moulton, MD
Address
Broad Street Plaza, Glens Falls, NY
Death Certificate Filed District Number Register Number
City, %MR MitifitXX G1 ens Fat 1 . 56n1
> t3Burial Date Cemetery or Crematory
03/13/2006 Pine View Cemetery
['Entombment Address
❑Cremation Queensbury, NY 12804
Date Place Removed
3❑Removal and/or Held
and/or Address
f=` Hold
Cl)
Date Point of
ti0 Transportation Shipment
a by Common Destination
in Carrier
❑Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan & Denny Funeral Home 01519
Address
53 Quaker Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
CC
fa
Permission is hereby granted to dispose of the human remains de cribed ab ve a ' dd'' ated.
Date Issued Registrar of Vital Statistics 4V t �
(signature)
District Number Place
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
tif Date of Disposition 3/13/06 Place of Disposition PINE VIEW CEMFTFRY.OUFFNSBI)RY NY
(address)
Ili
VI MOHICAN /-D 1
cc (section) (lot number) (grave number)
ct Name of Sexton or Perso in Charge of Premises MICHAEL GEN I ER
2 (please print)
Signature Title SUPT.
(over)
DOH-1555 (02/2004)