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Valastro, Dominic HX Date/Time 12/04/2018 •1849952 P.001 Dec 04 2018 03:06PM Alison Funeral Home 1 .� page 1 63 NEW YORK STATE DEPARTMENT OF H:. Vital Records Section y. Burial - Transit Permit Name First Middle Last Sex Dominic F.Valastro Male Date of Death Age If Veteran of U.S. Armed Forces, "' 12/02/2018 90 Years War or Dates 3 ' Place of Death Hospital, Institution or City, Town or Village Granville Town Street Address The Orchard Nursing And Rehabilitation Centre Manner of Death©Natural Cause El Accident `:Homicide El Suicide n Undetermined 11 Pending Circumstances Investigation Medical Certifier Name Title Leonard an MD Addressk 10421 State Route 40,Granville Town,N York 12832 Death Certificate Filed District Number Register Number City, Town or Village Granville 5756 63 ❑Burial Date Cemetery or Crematory 12/05/2018 Pine View Crematory El Entombment Address ®Cremation Queensbury, New York Date Place Removed l ❑Removal and/or Held and/or Address Hold Date Point of 0 Transportation Shipment by Common Destination Carrier 0 Disinterment Date Cemetery Address Renterment Date Cemetery Address -<< Permit Issued to Registration Number Name of Funeral Home Judson Funeral Home Inc 00885 Address 46 Williams Street,Whitehall Village,New York 12887 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Address Permission is hereby granted to dispose of the human remains described above as indicated. t Date Issued 12/04/2019 Registrar of Vital Statistics Jenny Linea Martell(fECectrnnica1Ty Signed) (signature) District Number 5756 Place Grahvile, New York I certify that the remains of the decedent dentified above were disposed of in accordancewith this permit on: Date of Disposition_ IZ kg Place of Disposition a // tJ(dress) hic`j04, (section) (loth fnber) (grave number) Name of Sexton or Person in Ch rge of F re ses (lillit•Jsepnpi Signature Title ifItt (over) DOH-1555 (02/2004)