Dachille, Dominick Clod
NEW YORK STATE DEPARTMENT Or'HEATH
Vital Records Section Burial - Transit Permit
.i Name First Middle Last Sex
Dominick A. Dachille Male
Date of Death Age If Veteran of U.S. Armed Forces,
12 / 13 / 2016 88 War or Dates Army
}- Place of Death Hospital, Institution or
City, Town or Village Stillwater Street Address 702 Route 9P
ttic3 Manner of Death riZ Natural Cause 0 Accident 0 Homicide O Suicide Undetermined �Pending
Circumstances Investigation
la Medical Certifier Name Title
0 David Shaffer MD
Address
42 New Scotland Ave. , Albany, NY 12208
Ei Death Certificate Filed District Number Register Number
City, Town or Village Stillwater -Y56 7 612.v2
>_OBurial Date Cemetery or Crematory
12 / 15 / 2016 Pine View Crematory
ni 0Entombment Address
EICremation Queensbury, NY
`' Date Place Removed
❑Removal and/or Held
3 and/or A
=` Hold Address
01
0 Date Point of __/
Q Transportation Shipment __
by Common Destination
Carrier
Disinterment Date Cemetery Address
INiQ Reinterment Date Cemetery Address
iiii Permit Issued to Registration Number
Oi Name of Funeral Home Compassionate Funeral Care 00364
ni Address
402 Maple Ave. , Saratoga Sp. , NY 12866
in Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
CC
ILI
A«' Permission is hereby granted to dispose of the human remains' escribe bove as i d.�
111< Date Issued /e -/J- 46Registrar of Vital Statistics i-i izi-i
(signatur
District Number -96 o 7 Place Stillwater , New York
' I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
tLI Date of Disposition/2/15,1/4, Place of Disposition - rh e of e 6fem4ioa,s
(address) /
tU
fiX
CC (section) ` (lo tuber) (grave number)
0 Name of Sexton or P r o iri Charge of Premises j / fCvt ( 96-mat, /.e
2 (please print)
41,
Signature Title C-re_ nc,/v
(over)
DOH-1555 (02/2004)