Mastrantoni lV, Rocco -�'- 2 a
NEWYORK STATE DEPARTMENT OF HEALTH _< . Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Rocco Mastrantoni IV Male
Date of Death Age If Veteran of U.S.Armed Forces,
03/07/2020 36 Years War or Dates
Place of Death Hospital,Institution or
WCity,Town or Village Lake George Village Street Address 80 Schuyler Street,Lake George Village,New York 12845
p Mannerof Death Ri Natural Cause Accident Homicide Suicide Undetermined Pending
W Circumstances Investigation
WMedical Certifier Name Title
Ageel Gillani MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Lake George Village 5620 1
Burial Date Cemetery,Crematory or Facility Name
03/10/2020 Pine View Crematory
Entombment Address
0 Cremation Queensbury Town,New York
Donation
z Removal Date Place Removed
and/or and/or Held
OH Hold Address
0
Vaj Transportation Date Point of
by Common Shipment
Carrier Destination
Disinterment
Date Cemetery Address
❑Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
_ Remains are Shipped,If Other than Above
Address
1E
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 03/10/2020 Registrar of Vital Statistics DeAra,7M--kinrreyg&trvnk 45Srgned)
(signature/
District Number 5620 Place Lake George Village, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: /��
W Date of Disposition �I��+'� Place of Disposition �.,
(address)
W
N (sed/on/ (tot number/ (grave numbed
Q
Name of Sexton or Person in Charge of remises
Z �A (p! se print)
W Signature L/�((/ /=::�c Title
DOH-1555(07/18)p t of 2
Public Health Law Sec. 4145(2b) 013 412
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#