De Respino, Louis NEW YORK STATE DEPARTMENT OF HEALTH / 31
Vital Records Section Burial - Transit Permit
f Name First Middle Last Sex
Louis Francis DeRespino Male
0f Date of Death Age If Veteran of U.S. Armed Forces,
January6 2017 80 War or Dates Arm
%'` Place of Death Hospital, Institution or
City, Town or Village Queensbury Street Address 511 Ridge Road
Manner of Death n Natural Cause n Accident n Homicide n Suicide n Undetermined n Pending
Circumstances Investigation
Medical Certifier Name Title
William Borgos,MD _
Address
><_ Queensbury,NY
f Death Certificate Filed District Number register Number
< City, Town or Village Queensbury, NY 5657 +-�
❑Burial Date Cemetery or Crematory
January 10, 2017 Pine View Crematorium
❑Entombment Address
®Cremation 51 Quaker Road, Queensbury, NY 12804
Date Place Removed
Z n Removal and/or Held
o and/or Address
Hold
N
O Date Point of
Nn Transportation Shipment
a by Common Destination
Carrier
El Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
0 Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Road, Queensbury, NY 12804
;�,f Name of Funeral Firm Making Disposition or to Whom
1' Remains are Shipped, If Other than Above
Address
Permission is here y granted to dispose of the human remains described b ve as indicated.
Alt Date Issued 1 C�) Registrar of Vital Statistics [ >C—�c , Q_---.1
.{z _ (signature)
Mi District Number �G� � d
Place i O Lo C'-¢-edD
I certify that the remains of the decedent identified above were disposed of in accorda ith this permit on:
wDate of Disposition j I II 117 Place of Disposition 'gt()ii.J erg► otorc�/
W (address)
CO
tY (section) /I (lot number) (grave number)
QName of Sexton or Person in Charge of remises l 4ry s+^l�
�Z (p ease print)
Signature 0 �1� 'l
Title `( �� -
(over)
DOH-1555(02/2004)