Cassella, Philip NEW YO'':( STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
i; Philip A. Cassella Male
Date of Death Age If Veteran of U.S. Armed Forces,
-July 17,2012 75 War or Dates n/a
"" Place of Death Hospital, Institution or
City, Town or Village Fort Edward Street Address Fort Hudson Nursing Home
Manner of Death a Natural Cause 0 Accident ❑Homicide n Suicide ❑Undetermined ❑Pending
Circumstances Investigation
Medical Certifier Name Title
William Tedesco,MD
rrw Address
,.x sr
Glens Falls,NY
Death Certificate Filed District Number Regis r mber
City,Town or Village Fort Edward,NY �7S G
®Burial Date Cemetery or rematory
❑Entombment July 21,2012 Pine View Cemetery
Address
❑Cremation Quaker Road, Queensbury,NY 12804
Date Place Removed
ZZ ❑Removal and/or Held
and/or Address
H Hold
N
0 Date Point of
N ❑Transportation Shipment
p by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Renterment Date Cemetery Address
Permit Issued to Registration Number
rf Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
;tom
,, Address
C.rj 407 Bay Road, Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
1 Remains are Shipped, If Other than Above
Address
,,-,,,,4 Permission is he eby anted to dispose of the human r ins described ove a indicated.
Date Issued /a _ Registrar of Vital Statisti AjAj
(signature) 7
-0 District Number Place Fort Edward,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 7/21 /201 2 Place of Disposition Pine View Cemetery _
2 (address)
W Erie 48 A 1
N
rt (section) (lot number) (grave number)
pName of exton or Person ' arge of Premises Michael Genier
Z4 t (please print)
W Signature' fAA.A .r_ Title Superintendent
(over)
DOH-1555(02/2004)