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JJ YORK STATE DEPARTMENT OF HEALTH BurialTransit S Permit
.al Records Section
2. Name First Middle Last Sex
—
�w II
ROBERT J. QEJOSEPH ; MALE
Date of Death Age If Veteran of U.S.Armed Forces,
10/27/2015 75 War ar D2rtee NO
Place of Death Hospital,institution COMMUNITY'HOSPICE OF'ALB'ANY 315
City,Town or Village City of Albany or Street Address S. MANNING BLVD
Manner of Death Natural Uhdeterrnined iPending
- ; Z Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ C�Ircunistahces; ❑ Investigation
1::::."z Medical Certifier Name — — -- — — Title
O. THEA DALFINO MD
Address
315 S. MANNING BLV
r Death Certificate Filed Cistric;Number Register Nurrber
7-- City, Town or Village City of Albany 101 j 2256
Date Cemetery or Crematory
„4: ❑Burial 10/2912015 PINE VIEW CREMATORY
>= ❑Entombment Address
D3 Cremation. QUEENSBURY, NY
-Wl-ri Date Place Removed
Removal41- andfor Neil
❑ andlor Address
Hold
44
Date Point of "`
.i Transportation Shipment
D By Common — —
&-_--r Carrier Destination
_ Date Cemetery Address —
t'�C Disinterment—
Date Cemetery Address
"° E Reinterment
iii ill
Permit issued To Registration Number
...5 N• ame of Funeral Home WILCOX& REGAN 01821
Address —_—_.�_� ___
11 ALGONKIN ST. TICONDEROGA NY 12883
Name of Funeral Firm Making Disposition or to Whom ---
R• emains are Shipped, If Other than Above
v.
Address
P• ermission is hereby granted to dispose of the human remains de bed a as Indicated. ,
Date 10/29/2015 e.v.-v✓L� �}- "
Issued Registrar of Vital Statistics --. e --.--_---_--
J
District Number 101 Place City o`Albany, NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on.
Date of Disposition /a!30I irr Place of Disposition vw -, (;)4Th.taiu...
rs: (address)
(section) ji (lot number) (grave number)
F°^ Name of Sexton or Person in Charge of Premises a(rl L— Sytti f t7-41
(please print) Y 117440140
=° Signature d Title
(over)
DOH-1555(02/2004)