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Nassivera, Matthew NEW YORK STATE DEPARTMENT OF HEALTH # 101I Vital Records Section Burial - Transit Permit Name First Middle Last I Sex Matthew Alan Nassivera Male Date of Death Age If Veteran of U.S. Armed Forces, December 19, 2018 60 War or Dates -ce of Death Hospital, Institution or �F Town or Village Saratoga Springs Street Address 342 Jefferson Street + anner of Death X❑Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined El❑ Pending Circumstances Investigation W Medical Certifier Name Title a Michael Sikirica MD, Address 50 Broad Street Waterford, NY 12188 th Certificate File _ District Number Register Number ' 'City Town or Village wtw 'y `�i j�- I (c�`( (_2 urial Date Cemetery or Crematory t December 21, 2018 Pine View Crematorium 444❑Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed z ❑ Removal and/or Held and/or Address Hold 0 Date Point of ck El Transportation Shipment {1t_ by Common Destination Carrier • ' ❑ Disinterment Date Cemetery Address • ❑ Reinterment Date Cemetery Address V• tl Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home, Inc. 00281 Address Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839 Name of Funeral Firm Making Disposition or to Whom =% Remains are Shipped, If Other than Above °z Address Or Ut t Permission is hereby granted to dispose of the human rem ' esc ibed above as indicated. ,�j[_ Date Issued I [ I L c,i.L CI, Registrar of Vital Statistics'j (sign ure District Number C Place rc-i-L 1 c (_. _ v c`1 C9— Jj.Ji t )L{ i 1\1 I I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: ut Date of Disposition 12/21/2018 Place of Disposition Quaker Road Queensbury,NY 12804 `" (address) a U?_ I) (section) (lot number (grave number) aName of Sexton or Person in Charge o Premises a wit(4L4/ r ase print) Signature w` Title ( `1 rJL (over) DOH-1555 (02/2004)