DelGato, Terry 14
NEW YORK STATE DEPARTMENT OF HEALTH` .
Vital Records Section Burial - TransTransit
zermit
Name First Middle Last Sex
Terry E. Del Gato Male
Date of Death Age ' If Veteran of U.S. Armed Forces,
May 11,2011 69 War or Dates Vietnam
Place of Death Hospital, Institution or
2, City, Town or Village Glens Falls I Street Address Glens Falls Hospital
US
ci Manner of Death I Xl Natural Cause Accident I I Homicide { Suicide I 1 Undetermined Pending
US Circumstances Investigation
us, Medical Certifier Name Title
P: Darci Gaiotti—Grubbs,MD
Address
"x Glens Falls,NY
Death Certificate Filed District Number Regi r umber
City, Town or Village Glens Falls,NY 5601 0
❑Burial Date Cem ery or Crematory n�
May 12,2011 l( U(ey.! eiriNVIVI
❑Entombment Address � n h /
0 Cremation a - -A- ' ram/ (.. �� bw h ) ( &�((x-�-
Date Place RemovJ , J _ f
Z - Removal and/or Held
and/or Address
Hold
N
O -
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
1 Remains are Shipped, If Other than Above
:X Address
te
A.t3
Permission is hereby granted to dispose of the human emains scribed ove as in. ..
Date Issued (15, L.Q OH Registrar of Vital Statistics O'LL,.� £ G%21--(.
(signature)
District Number 5601 Place Glens Falls,NY
I certify that the remains of the decedent identified above wer disposed of in accordance with this permit on:
W Date of Disposition 6/Iihl Place of Disposition Puulit.4 Ciunet 0 tkik
W (address)
Ie (section) (lot num r) (grave number)
Op Name of Sexton or Person in Charge of Premises ( <.S_p t.. -
Z (please print)
W
Signature Title C QE r tC(2-
(over)
DOH-1555(02/2004)