Ciminelli, James NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
James A. Ciminelli Male
Date of Death Age If Veteran of U.S. Armed Forces,
04/20/2011 73 years War or Dates
1,4. Place of Death Hospital, Institution or
iiiCity, Try Ii Saratoga Springs Street Address Saratoga Hospital
0:. Manner of Death D Natural Cause Accident Homicide 0 Suicide Undetermined Pending
uJ Circumstances Investigation
Medical Certifier Name Title
cf. Rodney Ying MD
Address
59 Myrtle Street Saratoga Springs, Ny
Death Certificate Filed District Number Register Number
City, T91909 Vim Saratoga Springs 4501 186
❑Burial Date Cemetery or Crematory
❑Entombment 04/21/2011 Pineview Crematorium
Address
[ Cremation Queensbury N Y
Date Place Removed
Z❑Removal and/or Held
2 and/or Address
F_- Hold
UU#
0 Date Point of
['Transportation Shipment
E, by Common Destination
Carrier
El Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Densmore Funeral Home 00442
Address
7 Sherman Ave, Corinth, New York 12822
Name of Funeral Firm Making Disposition or to Whom
1-4 Remains are Shipped, If Other than Above
2 Address
tr
il
Permission is hereby granted to dispose of the human re s scjed alo indica d.
Date Issued 04/21/2011 Registrar of Vital Statistics �,� —
(signature)
District Number 4501 Place Saratoga Springs
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z �
it Date of Disposition 4 h1 i iii Place of Disposition P,v )iJ Cr-0,4 or iv...
(address)
w
>I
1 (section) (lot num ) (grave number)
0
ti Name of Sexton or Person in Charge f Premises r-,t�_ .1.Vtt-
Z
(please print)
Signature
fi Title Cl/ell)tript'i..
(over)
DOH-1555 (02/2004)