VanAernem, Dale g tiNEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section
Burial - Transit Per it
Name First Middle Last Sex
Dale R. VanAernem Male
lii,:i Date of Death Age If Veteran of U.S. Armed Forces,
06 / 21 / 2017 58 War or Dates N/A
} Place of Death Hospital, Institution or
City, Town or Village Albany Street Address Albany Medical Center
IXI
g Manner of Death®Natural Cause Accident 0 Homicide C Suicide �Undetermined �Pending
Ui Circumstances Investigation
tg Medical Certifier Name Title
a Dana Cafaro NP
Address
47 New Scotland Ave Albany, New York 12208-3412
Death Certificate Filed District Number Register Number
i City,Town or Village Albany
0Burial Date Cemetery or Crematory
06 / 26 / 2017 Pine View Crematory
,' fEntombment Address
j ECremation Queensbury, NY
Date Place Removed
4❑Removal and/or Held
and/or Address
Hold
Date r _ :'`
0 Transportation :,-, iiprrie I.
6 by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
iiiPermit Issued to Registration Number
Name of Funeral Home Compassionate Funeral Care 00364
>s Address
il 402 Maple Ave., Saratoga Sp. , NY 12866
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
itE Address
it
I €
Permission is hereby granted to dispose of the hu mains described above as indicated.
Date Issued (P`2 41 f/ 7 Registrar of Vital Statistics ,,,, ` _
(signature)
District Number Place Albany , New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition P 174(tl Place of Disposition i'1i r (h'f`^etvPf t,--
a (address)
it
0
IZ (section) fof number) (grave number)
t' Name of Sexton or Person in Charge of P,,,fff���mises ` ruSI1IJ�ZL
//� (plea a print) •
Signature F�� j Title c �
6 (over)
DOH-1555 (02/2004)