Dalaba, Arnold NEW YORK STATE DEPARTMENT OF HEALTH `L
Vital Records Section Burial - Transit Permit
Name First Middle Last I Sex
Arnold Dalaba Male
Date of Death Age If Veteran of U.S. Armed Forces,
Nov 1, 2011 93 War or Dates No
1,,, Place of Death Hospital, Institution or Community Hospicelbany
City, TiiaXiXaX MICA a Albany Street Address @ St. Peter's Hospital
jManner of Death I XI Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
QMedical Certifier Name Title
Prabhna Kandiyil, MDAddress 315 So. Manning Blvd Albany, NY 12208
Death Certificate Filed T District Number Register N umber
City, TcogrixotNtipge Albany 101 0,CU,D'1
❑Burial Date Cemetery or Crematory
Nov 3 201 l Pineview Crematorium
Entombment Address
Cremation Queensbury, New York
Date Place Removed
Z Removal i and/or Held
0 and/or Address
H Hold
W —
—
0 Date Point of
NTransportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
: Permit Issued to I Registration Number
Name of Funeral Home Densmore Funeral Home 00428
.....,_Address — --- - —
7 Sherman Avenue Corinth, NY 12822
Name of Funeral Firm Making Disposition or to Whom
I Remains are Shipped, If Other than Above
Address
Ilt —
a£ Permission is here y granted to dispose of the human remains described above as indicated.
Date Issued 1 t, Z 3011 Registrar of Vital Statistics. -Q 5 Q L . (4_ 1 I•Q_d ,- -
(signature)
District Number \ Place L (:J-f PI a n ,
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition 1 I-4- ao it Place of Disposition rle cJ:>� Cc-ewt44-0r:uavi
2 (address)
W
CO
ae
(section t ;;�� (lot npmber) (grave number)
p Name of Sexton or Person in Char e of Premises 1 •, o4ki.j t;7Cuvvelle
(please print)
to Signature Title Cr-c,,,,e4
(over)
DOH-1555 (02/2004)