Dalaba, Addison NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Iliiiiiiic Name First Middle Last Sex
Addison Deleba male
s Date of Death Age If Veteran of U.S. Armed Forces,
Nov. .16, 1995 83 War or Dates no
.,_. Place of Death Hospital, Institution or
City, Town or Village Town of Argyle Street Address Pleasant Valley Infirmary
Manner of Death 0 Natural Cause 0 Accident 0 Homicide Suicide Undetermined 0 Pending
Ull Circumstances Investigation
tu Medical Certifier Name Title
fq Philip J. Gara MD
Address
7240 U•per Broadway, Fort Edward, N. Y. 12828
Death Certificate Filed District Number Register Number
City, Town or Village Town of Argyle
Date Cemetery or Crematory
®Burial November 18, 1995 Pine View Cemetery
Address
❑Cremation Queensbury, New York
Date Place Removed
2❑Removal and/or Held
... and/or Address
74 Hold
Q Date Point of
N0 Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
Permit Issued to Registration Number
'< Name of Funeral Home Regan and Denny Funeral Service, Inc. 01583
iiiiii Address
53 Quaker Road, Queensbury, New York 12804
Name of Funeral Firm Making Disposition or to Whom
r'" Remains are Shipped, If Other than Above
Address
`: Permission is hereby granted to dispose of the human remains described above as indicated.
IN Date Issued ////rI��•9 Registrar of Vital StatisticsEi,,,ta.d I latni...)
(signature)' 4
aDistrict Number 0 vJ`�0 Place 1ati -r, , • Q ,./, 7)
I certify that the remains of the decedent identified a ove were disposed of in accordance with this permit on:
ILI Date of Disposition 11 /18/9?lace of Disposition Pi np Vi Per Cemetery O„eengh„ry NY 1 7 2 fld
2 (address)
CIJ Hu.d.son # 1 30-D 1
CC (section) (lot number) (grave number)
OName of Sexton or Person in Charge of Premises Rodney C;_ Mosher
Z (please print)
t Signature 44)../v-14.1-t Title Sun'- .
DOH-1555 (10/89) p. 1 of 2 VS-61