Sassone, Mario NEW YORK STATE DEPARTMENT OF HEALTH .• w 41 Z3
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Mario J.
Sassone Male
Date of Death Age If Veteran of U.S. Armed Forces,
January 15, 2011 84 War or Dates World War II
is Place of Death Hospital, Institution or
.; City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death 0 Natural Cause 0 Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
j Medical Certifier Name Title
Joseph C. Mihindu, M.D. Dr.
Address
52 Park St. Glens Falls, NY 12801
-1-, Death Certificate Filed District Number Register Number
ri City, Town or Village _S 6 1 Z '.
❑Burial Date Cemetery or Crematory
January 18, 2011 Pine View Crematory
0 Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
and/or Address
Hold
.. Date Point of
-, ❑Transportation Shipment
by Common Destination
Carrier
❑ Disinterment Date Cemetery Address
❑ Renterment Date Cemetery Address
Permit Issued to
Registration Number
Y Name of Funeral Home M.B. Kilmer Funeral Home 01097
Address
136 Main Street, South Glens Falls NY 12803
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 1 ) + 120! ? Registrar of Vital Statistics 11)C^ '
k a (signature)
District Number
5 60 ( Place 6 19,A,,S \\
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
M
Date of Disposition 01/18/2011 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) /116 l (lot number) (grave number)
_' Name of Sexton o erson in Ch ge of Premises C itr‘sktektr S N.iii-
Signature Title
Ct(please
A print)
(over)
DOH-1555 (02/2004)