Canale, Nicholas NEW YORK STATE DEPARTMENT OF HEALTH U
Vital Records Section • ' N.. Burial - Transit rerm t
Name First Middle Last Sex
Nicholas Ulisse Canale Male
Date of Death Age If Veteran of U.S. Armed Forces,
November 16, 2012 69 War or Dates
! Place of Death Hospital, Institution or
City, Town or Village Argyle Street Address PLEASANT VALLEY NURSING FAC.
Manner of Death a Natural Cause Ei Accident El Homicide u Suicide n Undetermined ❑ Pending
Circumstances Investigation
Medical Certifier Name Title
" Barney Rubenstein, M.D. Dr.
KA
Address
eil Gilbert Street Cambridge, NY 12816: J Death Certificate Filed District Number%��7)V Register Number Lil` City, Town or Village J
0 Burial Date Cemetery or Crematory
I November 19, 2012 Pine View Crematorium
0 Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
• ❑ Removal and/or Held
and/or Address
Hold GERALD B.H. SOLOMON NAT.
til
(-
Date Point of CEM.
r C Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
❑ Reinterment Date Cemetery Address
• Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
,
Address
I,, Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
• Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
mi• Address
TO
. Permission is hereby granted to dispose of the human re ains described above as indicated.
Date Issued 1 i f iq/ia Registrar of Vital Statistics crtAjctN1
(signature)
gib Place i V UL.
District Number
f(
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition Il]jo I t2. Place of Disposition -.0,..cUyt.) ('« i'i---
(address)
tc
(section) (lot number) (grave number)
Name of Sexton or Person in Charg of Premises pent)
Signature Title £/
(over)
DOH-1555 (02/2004)