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Anselmo, Joseph M.
10 - . _. #gi s NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Joseph M Anselmo Male Date of Death Age If Veteran of U.S.Armed Forces, 12/05/2019 35 Years War or Dates E,.. Place of Death Hospital,Institution or Z City,Town or Village Hadley Town Street Address 1207 Stony Creek Road, Hadley Town, New York 12835 W Manner of Death Undetermined Pending G Natural Cause Accident Homicide Suicide © g W Circumstances Investigation V W Medical Certifier Name Title Eugene Ladue Coroner Address 31 Woodlawn Ave.,Saratoga Springs, New York 12866 Death Certificate Filed District Number Register Number City,Town or Village Hadley 1 4558 14 ❑Burial Date Cemetery,Crematory or Facility Name 12/10/2019 Pine View Crematory Entombment Address iCremation Queensbury Town, New York ❑Donation 0 ❑Removal Date Place Removed and/or -7 and/or Held �- Hold Address N O a. Date Point of to ❑Transportation p by Common Shipment Carrier Destination Disinterment Date Cemetery Address Date Cemetery Address Reinterment Permit Issued to Registration Number Name of Funeral Home Brewer Funeral Home Inc 00211 Address 24 Church Street PO Box 500, Lake Luzerne, New York 12846 Name of Funeral Firm Making Disposition or to Whom IN Remains are Shipped,If Other than Above g Address Q W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 12/09/2019 Registrar of Vital Statistics P,"JneG9n3Fd(E16frcrid1y9976j /signature) District Number 4558 Place Hadley, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: F— Z Date of Disposition I2'il III Place of Disposition ,u J�,,./ (r OtWr- LU (address) W O (section) r(lot number) (grave number) c Name of Sexton or Person in Charge of Premises (please print) W Signature L.J //err TitleM DO H-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) 013 14,01 Receipt Human remains o£ � V' 1 delivered on _ , 20 Pine View Cemetery Repfe!�edting the funeral home named on burial permit Official Funeral Directors Reg.or License#