Deloriea, Samuel II ii
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Samuel E.H.Deloriea Male
Date of Death Age If Veteran of U.S. Armed Forces,
02/06/2018 56 Years War or Dates
Place of Death Hospital, Institution or
City, Town or Village Saratoga Springs Street Address Saratoga Hospital
Manner of Death Ai Natural Cause ❑Accident ❑Homicide ❑Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Numan Rashid MD
Address
211 Church St,Saratoga Springs,New York 12866
Death Certificate Filed District Number Register Number
City, Town or Village Saratoga Springs 4501 88
7,1�,�; ❑Burial lDate Cemetery or Crematory
02/08/2018 Pineview Crematory
❑Entombment Address
®Cremation Queensbury Town, New York
Date Place Removed
❑Removal and/or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment
by Common Destination
7 Carrier
;fi. •
Q Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
N
Permit Issued to Registration Number
Name of Funeral Home Densmore Funeral Home Inc 00448
Address
7 Sherman Ave,Corinth,New York 12822
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 02/07/2018 Registrar of Vital Statistics John pFranck(fEfectronicaICySigned)
(signature)
. District Number 4501 Place Saratoga Springs, New York
tiii I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition ZI 9 fl( Place of Disposition t/»U✓ /a.c.+_
11. (address)
at (section) %/ (lot number . (grave number)
Name of Sexton or Person in Charge of Premi es 6 LP,, 31,iC'
please print)
Signature Title l i i Es fia-
(over)
DOH-1555 (02/2004)