Roccasecca, Salvatore r .
-wo,' — it 7t/j
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Salvatore Michael Roccasecca Male
Date of Death Age If Veteran of U.S. Armed Forces,
Oct 11, 2016 32 War or Dates
Place of Death Hospital, Institution or Westchester Medical Center
Town of Mt. Pleasant
Z City, Town or Village Street Address Valhalla, New York 10595
Manner of Death gNatural Cause 0 Accident 0 Homicide 0 Suicide 0 Undetermined ri Pending
E1 Circumstances Investigation
W Medical Certifier Name Title
C} Sachin Sule MD
Address
Westchester Medical Center, Valhalla, New York 10595
Death Certificate Filed Town of Mt. Pleasant District Number 5957 Register Number
`: City, Town or Village 637
['Burial Date Cemetery or Crematory
Oct 14, 2016 Pine View Crematorium
gi❑Entombment A
III EgCremation _ Queensbury, NY
ate Place Removed
t Removal and/or Held
c.❑and/or Address
F=` Hold
CA
C Date Point of
0 Transportation Shipment
G by Common Destination
Carrier
im
illiiEl Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home Inc. 00281
iii Address
giiiil 68 Main STreet, P 0 Box 67, Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
1 ; Remains are Shipped, If Other than Above
Address
t . --
Permission is hereby granted to dispose of the human remains scribed above-as indicated.
Date Issued 10/13/2016 Registrar of Vital Statistics / , fib.
(si 'ure) T - -
District Number 5957 Place One Town Hall Plaza, Valha3 1z -_New York 10595
I certify that the remains of the decedent identified above were disposed of in accordance with-this permit on:
2 enttLi_
ill Date of Disposition F 1 I11 Ib Place of Disposition _(f'f"'Vt`4.,.,
2 (address)
la
fill
CC (section) / (lot number) ,- (grave number)
QName of Sexton or Person in Charge of P emises diro�p J44,441
2 (p ase print)
Signature a Title (KMAPil
(over)
•
DOH-1555 (02/2004)