DeCastro, Percy NEW YORK STATE DEPARTMENT OF HEALTH 4
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Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Percy Gabriel DeCastro Male
Date of Death Age If Veteran of U.S. Armed Forces,
11/13/2018 60 War or Dates NA
N Place of Death Hospital, Institution or
Z City, Town or Village Town of Johnsburg,NY Street Address 308 Riverside Station Rd.,Riparius,NY 12862
pManner of Death C Natural Cause ❑Accident --Homicide [J Suicide 0 Undetermined n Pending
tii Circumstances Investigation
au Medical Certifier Name Title
G Daniel Larson MD
Address
6223 State Route 9,Chestertown,NY 12817
Death Certificate Filed District Number Register Number
City, Town or Village Town of Johnsburg,NY
0 Burial Date Cemetery or Crematory
Entombment November 15, 2018 Pine View Crematorium
Address
®Cremation 51 Quaker Road, Queensbury,NY 12804
Date Place Removed
ZZ t Removal and/or Held
9. and/or Address
H Hold
N
0 Date Point of
e5 E Transportation Shipment
p by Common Destination
Carrier
C Disinterment Date Cemetery Address
1-1 Renterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Road,Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
i- Remains are Shipped, If Other than Above
a Address
et
Q. Permission is he a 7cJé4'1 eby ranted to dispose of the human rem s described abov!(D,r'
indicated.
Date Issued }� ! (�j Registrar of Vital Statisticse-
(signature) � p
District Number 6 CS Place
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition f/-/6 r/Q Place of Disposition ;,h2 v ;4_,-1 fit,4 4r iv.rt
W (address)
Cl)
0 (section) (lot number) (grave number)
pName of Sexton P 'n Charge of Premises �Lt/i G,,n (74.yrt (.4-c,4.-e
Z (please print)
u.,
Signature Title �� 4-fU,--
(over)
DOH-1555(02/2004)