D'Addetta, Douglas 4 2z1
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
741 Name First Middle Last Sex
,' Douglas D'Addetta
Mate
As Date of Death Age If Veteran of U.S. Armed Forces,
;" 03/15/2018 60 Years War or Dates 1975-1976
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
0 Manner of Death® Natural Cause Accident ❑Homicide Suicide Undetermined ❑Pending
la Circumstances Investigation
ui Medical Certifier Name Title
Stephen Perazzelli MD
Address
kg 100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
.f City, Town or Village Glens Falls 5601 137
iii 0 Burial Date Cemetery or Crematory
03/19/2018 Pine View Crematorium
❑Entombment Address
,®Cremation Queensbury Town, New York
e Date Place Removed
❑Removal and/or Held
C and/or Address
P Hold
ill —
Date Point of
❑Transportation Shipment
""" by Common Destination
.:t Carrier
Q Disinterment Date Cemetery Address
h ❑Reinterment Date Cemetery Address
4 Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home Inc 00281
Address
t, 68 Main Stpo Box 67,Hudson Falls,New York 12839
Name of Funeral'Firm Making Disposition or to Whom
Remains are Shed, If Other than Above
a Address
W
! Permission is hereby granted to dispose of the human remains described above as indicated,
Date Issued 03/19/2018 Registrar of Vital Statistics Robert_A Curtis t'E(ectronu.4Qy Sgned)
e (signature)
District Number 5601 Place Glens Falls, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ri
Date of Disposition 3)LI (I g Place of Disposition,V
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(addre s)
5
i (section) lot number) (grave number)
Name of Sexton or Person in Charge f Premises Cr, ""'�
(p1 Se prim
la i f
," Signature _ Titlerp
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(over)
DOH-1555 (02/2004)