Salamore, Peter NEW YORK STATE DEPARTMENT OF HEALTH 4 (A
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
:2+-.76' Jo vph Sas r�76Yu- Al
Date of Death Age If Veteran of U.S. Arme Forces,
/p/a 7/1b War or Dates
�- Place of Dea City, Hospital, Institution or � '��.
2 Town or VillageS��a{JX t S �a{���1) Z�pcmgc Street Address "V
la Manner of Death latural Cause 0 Accident 0 Homicide 0 Suicide 111 Undetermined El Pending
W. Circumstances Investigation
til Medical Certifier Name Title
2 I/ 0 it)k rchss s Scuaiteyo Springy AJ y l e g to b
Death Certificate Filed District Number Register Number
it �own or Village SARATOGA SPRINGS l
Date Crematory,metery or Cremato
❑Burial / G ZG� /3 i n e V 1• C' rnc.-o 2y
:❑Ent bment
Addres
1111111 remation c i Qt.t..6041-12 R d. 6 ( Q-t
- 7S h i , 7 , 2U 0 7
Date Place Removed
Q9ni Removal and/or Held
and/or Address
I= Hold
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0 Date Point of
Transportation Shipment
0 by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration N mber
Name of Funeral Home C()NyeLSS( Ortt-le 4ultra_( av 10 C . (X) (Q C/
Address
too Make ii AlAa2 Sal -a- $prtn.�� AJ y /2 g
Name of Funeral Firm Making Disposition Orto Whom
Remains are Shipped, If Other than Above
Address
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,.7 Permission is hereby granted to dispose of the human remai ri d a 'ndicate
11111111111 Date Issued (C/2S j2Gu13 Registrar of Vital Statistics
(signature)
Nii District Number 50l Place SARATOGA SPRINGS
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
111 Date of Disposition/(]3/-/3 Place of Disposition f/vv'L imr.,f l et-oi r/ zt
2 (address)
LU
Cl)
/
n- (section) `, (lot number) (grave number)
0
Ci Name of Sexto r Person .-r ,arge of Premises J e-i � 4 it)inn�.
r
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(please print)
linSi V /gnature Title t t a 17,E AS J.
d
(over)
DOH-1555 (02/2004)