DelSignore, Albert tt
NEW YORK STATE DEPARTMENT OF HEALTH ,. .ISI `3
Vital Records Section Burial - Transit Permit
: Name First Middle Last Sex
Albert J. DelSignore Male
°' Date of Death Age If Veteran of U.S. Armed Forces,
March 11, 2011 96 War or Dates
} Place of Death Hospital, Institution or
Z City, Town or Village Queensbury Street Address Stanton Nursing & Rehab Centre
iii
a Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
lit Circumstances Investigation
us Medical Certifier Name Title
PA Roslyn Socolof,MD
Address
r Queensbury,NY
3, Death Certificate Filed District Number Rc inter Number
City, Town or Village Queensbury,NY 5657 pt
❑Burial Date Cemetery or Crematory
March 15, 2011 , Pine View Crematory
❑Entombment Address
li Cremation Quaker Road, Queensbury, NY 12801
Date Place Removed
Z Removal and/or Held
and/or Hold Address
I=
0 Date Point of
NTransportation Shipment
p by Common Destination
Carrier
Disinterment Date ' Cemetery Address
Reinterment
Date Cemetery Address
I
Permit Issued to Registration Number
Name of Funeral Home Singleton- Healy Funeral Home 01622
Address
`', 407 Bay Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
k Remains are Shipped, If Other than Above
5 Address
lit
, Permission is hereb granted to dispose of the human rem ins describedabove as indicated.
Date Issued ( (` Registrar of Vital Statistics G, / ILLS
(signature)
District Number 5657 Place Queensbury,NY
I certify that the remains of the decedent identified above were disp sed of in accordance with this permit on:
W Date of Disposition 3-11-'1\ Place of Disposition ►r►c'v,tw C.RA.(101.i`
2 (address)
W
U)
0' (section) (lot num (grave number)
Q Name of Sexton or Person in Charge of P emises r,*
W f_i (please print)
Signature C/,!/i/� L Title Ci2t)its f oe,
(over)
DOH-1555(02/2004)