Deluca, Nicholas # ISO
NEW YORK STATE DEPARTMENT OF HEALTi"
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Nicholas DeLuca Male
Date of Death Age If Veteran of U.S. Armed Forces,
Miii 03/08/2015 55 years War or Dates Yes
14 Place of Death Hospital, Institution or
Ul
si)t Jown or C Wilton Street Address 41 Castleberry Drive
0 Manner of Death I,Natural Cause Accident Homicide El Suicide riUndetermined ri Pending
Iti Circumstances Investigation
ul Medical Certifier Name Title
Michael Sikirica Md
Address
50 Broad Street Waterford Ny 12188
Death Certificate Filed District Number Register Number
mown or 1400xxx Wilton 4569 15
>>0 Burial Date Cemetery or Crematory
l' ❑Entombment 03/11/2015 Pine View Cemetery
Address
QCremation Queensbury
Date Place Removed
gRemoval and/or Held
'.'R and/or Address
h Hold
Date Point of •
CtiQ Transportation Shipment
a by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address ii:
Permit Issued to Registration Number
Name of Funeral Home Compassionate Funeral Care, Inc 00364
liN Address
402 Maple Ave. Saratoga Springs N Y 12866
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
t
Ili
Permission is hereby granted to dispose of the human remains described above s iinnfdi ated.
Date Issued 03/11/2015 Registrar of Vital Statistics #/ ./�
(signature
District Number 4569 Place Wilton
i_il>.::: I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILI Date of Disposition 3 i ohs- Place of Disposition 'µ V tv ( i-lor—
(address)
Ui
w
LE (section) 1 (lot number4 (grave number)
ci G
Name of Sexton or Person in Charge of Premises °a - tnwt-
(please print)
Signature 1,.. Title (17.:fAWtpit
(over)
DOH-1555 (02/2004)