LoSacco, Peter NEW YORK STATE DEPARTMENT OF HEALTH 4 VS43
Vital Records Section Burial - Transit Permit
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rName First Middle Last Sex
Peter Steven LoSacco Male
▪ Date of Death Age If Veteran of U.S. Armed Forces,
June 28,2015 72 War or Dates Air Force
Place of Death Hospital, Institution or
City, Town or Village Saratoga Springs,NY Street Address 25 Nelson Street
Manner of Death 0 Natural Cause ❑Accident ElHomicide ❑Suicide Undetermined n Pending
Circumstances Investigation
Medical Certifier Name Title
Aqeel Giillanii,MD
Address
Glens Falls,NY
j'f Death Certificate Filed District Number Register j ber
City, Town or Village Saratoga Springs, NY 4501 in
❑Burial Date Cemetery or Crematory
[1 Entombment July 1, 2015 Pine View Crematorium
Address
®Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
ZZ ❑Removal and/or Held
and/or Address
H Hold
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0 Date Point of
• Transportation Shipment
p by Common Destination
_Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
. Permit Issued to Registration Number
j Name of Funeral Home Re.an Denn Stafford Funeral Home 01443
Address
3 53 •uaker Road, I ueensbur NY 12804
/4 Name of Funeral Firm Making Disposition or to Whom
„,e Remains are Shipped, If Other than Above
;+ Address
• Permission is h eby ranted to dispose of the human remains on deovel! cated.
Date Issued . Registrar of Vital Statistics
(signature)
• District Number 1.1,5Dj( Place � s rx.A. ' )�
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
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1,11 Date of Disposition 7—i—t5 Place of Disposition the v.4t...! U'tv►.4-or':Om
(address)
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N
W ,(section) (lot number) (grave number)
0 p Name of Sexton or Person in C rge of Premises1 Ism p4.k�r r+t'(<<
Z �� I (please print)
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Signature Title Cl`ew,0„'ktft'7 4514(
(over)
DOH-1555(02/2004)