Paniccia Sr., Dominic f 41 sell
NEW YORK STATE DEPARTMENT OF HEALTH •
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Dominic Thomas Paniccia Sr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
10/28/2018 86 Years War or Dates Navy
Place of Death Hospital, Institution or
City, Town or Village Queensbury Town Street Address Warren Center for Rehabilitation and Nursing
Manner of Death r Natural Cause El Accident Homicide Suicide riUndetermined ri Pending
Circumstances Investigation
Medical Certifier Name Title
Roslyn Socolof MD
Address
42 Gurney Ln,Queensbury Town,New York 12804
Death Certificate Filed District Number Register Number
City, Town or Village Queensbury 5657 154
❑Burial Date Cemetery or Crematory
10/31/2018 Pine View Crematory
❑Entombment Address
®Cremation Queensbury, New York
Date Place Removed
Removal and/or Held
and/or Address
Hold
Date Point of
Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Rd,Queensbury,New York 12804
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.
Date Issued 10/31/2018 Registrar of Vital Statistics Caroline 9f BarderOctronicaffySigned)
(signature)
District Number 5657 Place Queensbury, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 0/31 JI$ Place of Disposition
(address)
(section) 4(lot number) (grave number)
Name of Sexton or Person in Charge of Premises
03 se print)
Signature G.l /�rr Title TTe
(over)
DOH-1555(02/2004)