Romeo, Joseph NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
':tip Joseph _ Romeo Male
f, Date of Death Age If Veteran of U.S. Armed Forces,
r November 10, 2014 81 War or Dates
''•j Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death n Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
're: Sanueh Follerman
:7 Address
1 90 South Street,Glens Falls,NY 12801
1: Death Certificate Filed District Numbe5601 Register Number 51 F
* City, Town or Village Glens Falls �/
0 Burial Date Cemetery or Crematory
❑Entombment 1 1 i /4 1)-0\ Pine View Cemetery
Addres
❑Cremation Quaker Road, Queensbury, , NY 12804
Date Place Removed
ZO I I Removal and/or Held
and/or Address
E Hold
m
O Date Point of
N I I Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
,; :' Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
.r:} Address
53 Quaker Road, Queensbury,NY 12804
xtir Name of Funeral Firm Making Disposition or to Whom
I'? Remains are Shipped, If Other than Above
: Address
f;; Permission is hereby granted to dispose of the human remains described above as indicated.
r" Date Issued i I2. I';�:; ) / cl Registrar of Vital Statistics 1n1 c�,l�,�
(signet e)
5601
�: District Number Place Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordancel ,'with this permit on:
. C�*_./,,6 P/l.Ski/Az/ N'i /� t"
W Date of Disposition /` /�/ /� Place of Disposition �� A��r 8U
W / (address)
CO \(S o 74-
re
(secjimp 666z(lot number) (grave number)
G Name of Sexton or Person in Charge of Premises tic)/G L--
Z (p ase print)
W /J __
Signature , , . . Q - Title 0.42/1- gc
1.771__ (over)
DOH-1555(02/2004)