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DeRosa, Peter 4. NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex 0: Peter DeRosa Male :▪ Date of Death Age If Veteran of U.S. Armed Forces, August 12, 2015 91 War or Dates r¢ Place of Death Hospital, Institution or City, Town or Village Glens Falls Street Address The Pines Of Glens Falls • Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending Circumstances Investigation Medical Certifier Name Title 0Melissa Decker MD r1 Address 9 Carey Road,Queensbury,NY 12804 :::ix Death Certificate Filed District Number Register)',um er :§; City, Town or Village Glens Falls, NY 5601 V i Burial Date Cemetery or Crematory August 17, 2015 Pine View Cemetery ❑Entombment Address ❑Cremation Quaker Road, Queensbury, NY 12804 Date Place Removed Z Removal and/or Held and/or Address H Hold N O Date Point of NTransportation Shipment a by Common Destination Carrier Disinterment Date Cemetery Address n Reinterment Date Cemetery Address r, Permit Issued to Registration Number :: Name of Funeral Home Regan Denny Stafford Funeral Home 01443 ::; Address r 53 Quaker Road, Queensbury,NY 12804 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 abo icated. :•' Date Issued c� 4 C'"'"0 , p� i Registrar of Vital Statistics (signature) ;i:§ District Number ....> / Place Glens Falls,NY ,i 2 O/ I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: W Date of Disposition 8/1 7/1 5 Place of Disposition Pine View Cemetery, Quecnshtnry, Ny W (address) U) Erie 64C 2 (section) (lot number) (grave number) G • Name of Se nor Person in Charge ises Connie L. Coedert Z ✓ �. (please print) W Signature•'l-©1L of Prem Title Cemetery Superintendent r (over) DOH-1555(02/2004) 1