DeSanctis, Mario NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Mario Bruno DeSanctis Male
Date of Death Age If Veteran of U.S. Armed Forces,
January 5,2014 85 War or Dates
Place of Death Hospital, Institution or
Z City, Town or Village Queensbury Street Address 70 Peggy Ann Road
pManner of Death ki Natural Cause n Accident L Homicide n Suicide n Undetermined Li Pending
W Circumstances Investigation
W Medical Certifier Name Title
Ci Craig Emblidge
Address
Three Irongate Center,Glens Falls,NY 12801
Death Certificate Filed Queensbury I District Number Register Number
City,Town or Village 5657 a
❑X Burial Date Cemetery or Crematory
January 8,2014 Pine View Cemetery
❑Entombment Address
❑Cremation Quaker Road, Queensbury, ,NY 12804
Date Place Removed
Z n Removal and/or Held
O and/or Address
I' Hold
V)
0 Date Point of
N n Transportation Shipment
a by Common Destination
Carrier
n Disinterment Date Cemetery Address
n Renterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Road, Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
I- Remains are Shipped, If Other than Above
2 Address
Et
W
a. Permission is herby granted to dispose of the human remains described above as indicated.
Date Issued l I -) I oiy Registrar of Vital Statistics 1c_ci , 6, ,.
(signature)
District Number 5657 Place Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z IPine View Cemetery
W Date of Disposition 14$ (IL! Place of Disposition
2 (address)
W N Seneca 32 F 1
fY (section) (lot number) (grave number)
QName of Se on or Person in Charge of Premises Connie L. Goedert
(please print)
W Signature , P� Title Superintendent
(over)
DOH-1555(02/2004)