DiBenedetto, Gasper 11 iN, I/ 113
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
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Name First Middle last - 2 ne I Sex
C aSQ-ef �, t C
Date of Death Age [ If Veteran of U.S.Armed Forces,
j�22�2O I 1 �- SC or Dates ) S5- - 1 y(off.
Place of Death i Hospital, Institution or
Giti. ►J own Village �/ ���Vi( Street Address aq 1 kko Mi-h. o UQ�
in Mann eathz3 Natural Cause D ccident ❑Homicide Suicide fl Undetermined 0 Pending
€ Circumstances Investigation
9 c
Medical Certifier Name Title �h
0 (:111 / Saws
Address 1 IQ 1 eina-Cc,I a- 1 o ueQ1-r h u r V i YV N J O y
Deal: ^ -icate Filed /� , District Number ; egister Number
CityTown or Village V 1115�%j Ur� l (,pc i It
Date i Cemetery o Crematory
OSunai 1 sl.zy 1 1 't v i t 0
RFntombrnentI Address f h /�(
OCr ematiai i Q Vee nkO�;\ c.-� i \`; 12-s O 7
I Date J i Place Removed
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� � ��- Arai and/or Held
a idior
rzi Address
-!old
esi
Date 1 Point of
F i Transportation Shipment
Vvf Common i Destination
7-4 Carrier
i;Disinterment
Date i Cemetery Address
I ! Date Cemetery Address
#E r5e,rite'riierit
` Permit Issued to a I Registration Number
:::i Name of Funeral Home Baker Funeral Home 01130
Ad= Gss -
11 Lafayette St., Queensbury, NY 12804
Na:t i?of Funeral Firm Making Disposition or to Whom
�I Pe -, :r s are Shipped, If Other than Above
al
fifi„i
c
.. # PE e,,,, s on is hereby grenated to di000se of the human re ells described above es indicated.
. Date iSSUE? , 1 c).y 1 -Gt k Registrar of Vital Statistics Ck C)
(signature)
. District Numberc(c 1 Place l 0 U-m VY 0 kxb...-N
ice€ I c er y that the remains of the decedent identified above were disposed of in orda ce with this permit on:
Mi LUi Date cif isposition Si ZS II$ Place of Disposition "i'
u to d—
VA
(address)
fio'
(section) (lot numb (grave number)
pi Name of Sexton or Person in Charge of Premises iV� 4II
LI' ff (F a print)
.1 Signature L,( Title - (tf<A►11,1_
(over)
DOH--i 555 (02/2004)