Meldola, Mark NEW YORK STATE DEPARTMENT OF HEALTH ' B ��
Vital Records Section urial - ranSlt Permit
Name First Middle Last Sex
MARK REED MELDOLA MALE
Date of Death Age If Veteran of U.S.Armed Forces,
10/15/2015 74 War or Dates 1964-1969
I. Place of Death Hospital, Institution
City ,Town or Village City of Albany or Street Address ALBANY MEDICAL CENTER
GManner of Death Natural Undetermined Pending
{[ ® Cause ❑ Accident ❑ Homicide ❑ Suicide El ❑ Investigation
W Medical Certifier Name Title
Ca RALPH DARLING MD
Address
43 NEW SCOTTLAND AVE ALBANY NY 12208
Death Certificate Filed District Number Register Number
City,Town or Village City of Albany 101 2172
Date Cemetery or Crematory
❑ Burial 10/22/2015 PINE VIEW CREMATORY
❑ Entombment Address
® Cremation QUEENSBURY, NY
Date Place Removed
Z Removal and/or Held
Q` ❑ and/or Address
" Hold
CO
Q Date Point of
a Transportation Shipment
O ❑ By Common Destination
CI Carrier
❑ Date Cemetery Address
Disinterment
ElDate Cemetery Address
Renterment
Permit Issued To Registration Number
Name of Funeral Home BAKER FUNERAL HOME 01130
;' Address
11 LAFAYETTE ST. ST. QUEENSBURY NY 12084
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
• Address
U.1
Q. Permission is hereby granted to dispose of the human remains des !bed ib*ve as indicated.
Date 10/22/2015 Registrar of Vital Statistics -4'-��'2 A-� x •�
Issued �'�i
District Number 101 Place City of Albany, NY
I certify that the remains of the decedent identified above were disposed of in accordance with thish permit on:
Z Date of Disposition ld1 Z'5//S- Place of Disposition 40..., (, nfw"-/
W' (address)
La
co
0 ((section) (lot number) (grave number)
�Z Name of Sexton or Person in Charge of Premises
(please print)
Signature it Title el 4W--
(over)
DOH-1555 (02/2004)