Marseglia, Dominick NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle' Last Sex
Dominick Marseglia Male
Date of Death Age If Veteran of U.S.Armed Forces,
February 2,2006 0 War or Dates
Place of Death Hospital, Institution or
gCity, Town or Village Town of Johnsburg Street Address 251 Main St.,North Creek
W Manner of Death ❑ Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined J Pending
Circumstances Investigation
✓ Medical Certifier Name Title
Michael Sikirica Medical Examiner
Address
50 Broard St.,Waterford,NY 12188-
Death Certificate Filed District Number Register Number n
City,Town or Village Town ofJohnsburg 5655
❑ Burial Date Cemetery or Crematory
2/10/2006 Pine View Crematory
❑ Entombment Address
0 Cremation Queensbury,NY
Date Place Removed
ElRemoval
ZO and/or Held
and/or Address
• Hold
Date Point of
Q.• ❑ Transportation Shipment
! by Common Destination
Carrier
Date Cemetery Address
❑ Disinterment
Date Cemetery Address
❑ Reinterment
Permit Issued to Registration Number
Name of Funeral Home Alexander Funeral Home,Inc. 00037
Address
4479 State Route 28,North River,NY 12856
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
- Address
Permission is hereby granted to dispose of the human remains described aboy ass indicated.
Date Issued 2/08/2006 Registrar of Vital Statistics (`.aQQ�-�-
(signature)
District Number 5655 Place Town of Johnsburg Clerk,Town Hall,North Creek,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z▪ Date of Disposition a-1-o Ce Place of Disposition /0 "/E l/i lt� e-r2EA eizt,'Ll,cam
(address)
2
W
N (section) (lot number) (grave number)
G •t�az�Name of Sexton or Person in Charge of Premises G . Co-t��'�i rV
4-
(please print)
W Signature �sc,�,c,, �,,�'� Title Ct2 %er+d'�
DOH-1555 (02/2004) (over)