DelMonaco, John 3Sc
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
iiiiiiii Name First Middle Last Sex
M. John • DelMonaco male
» Date of Death Age If Veteran of U.S. Armed Forces,
08/22/2006 84 War or Dates WWII
14 Place of Death Hospital, Institution or
1j City, ittitvnixsAAIIngt Glens Falls Street Address Glens Falls Hospital
0 Manner of Death®Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined El Pending
E. Circumstances Investigation
tu Medical Certifier Name _. Title
Jonathan DeSantis, MD
Address
Upper Glen Street, Queensbury, NY 12804
Death Certificate Filed District Number Register Number
City, T&X,14NIMIteicja Glens Falls 5601 •
9/2-
❑Burial Date Cemetery or Crematory
08/25/2006 Pine View Crematory
❑Entombment Address
®Cremation Queensbury, NY 12804
Date Place Removed
❑Removal and/or Held
and/or Address
t Hold
in
(Z Date Point of
1 Transportation Shipment
E by Common Destination
Carrier
`< Q Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan & Denny Funeral Home 01519
:• Address
53 Quaker Road, Queensbury, NY
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
• Address
IX
U1
Permission is here y gr nted to dispose of the human remains d cr'be ab a as, r •ated.
Date Issued fS ZS 0'd Registrar of Vital Statistics 6 '• '•
/_ (signature)
District Number �60/ Place 6p/��„ti ,f/•//�,/Uy
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
LEI• Date of Disposition j4g/v6 Place of Disposition tineUlrw Crt,n.c,to i v+-
(address)
t;Lt
0
ir (section) (lot number) (grave number)
tt Name of Sexton or Person -n Charge of Premises ell r> > So nn t U-
Z (please print)
:;: Signature ( L um'"t, -- Title (rim 4-{u r
(over)
DOH-1555 (02/2004)