Basta, Mario rfi
NEv1/YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
3., Marto Anthony Basta Male
Date of Death Age If Veteran of U.S. Armed Forces,
05/26/2018 68 Years War or Dates 1969-1972
Place of Death Hospital, Institution or
tia City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death irgli Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ri❑Pending
Circumstances Investigation
Medical Certifier Name Title
Shahid Ahmed MO
Address
100 Park St,Glens Falls,New York 12801
j Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 260
l❑Burial Date Cemetery or Crematory
05/29/2018 Pine View Crematorium
❑Entombment Address
' ®Cremation Queensbury Town. New York
Date Place Removed
❑Removal and/or Held
P. - and/or Address
Hold
40
Date Point of
❑Transportation Shipment
51 by Common Destination
Carrier
❑Disinterment
Date Cemetery Address
❑Reinterment Date Cemetery Address
;E.', Permit Issued'to Registration Number
Name of Funeral Home Carleton Funeral Home Inc 00281
Address
68 Main Stpo Box 67,Hudson Falls,New York 12839
" Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
w
` Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 05/29/2018 Registrar of Vital Statistics Robert ri Curtis(EtcctroiticatrySigned+
E:
(signature)
District t 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:
PI
U Date of Disposition 3o/ Place of Disposition Piiieiiil'ew/
ere hu,, La_).iti ,,,, _
(address)
(section) Jot number) . (grave number)
Name of Sexton or P rson in G rge of Premises 57:eph,e / j ,4 U✓S 51
/j (please print)
LU
Signature Title l E1' a* r.,>a.,
(over)
DOH-1555(02/2004)