Palazzo, James NEW YORK STATE DEPARTMENT OF HEALTH s, S13
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
James P. _ Palazzo Male
Date of Death Age If Veteran of U.S. Armed Forces,
October 5,2013 59 War or Dates
F,. Place of Death Hospital, Institution or
Z City, Town or Village Bolton Landing Street Address 424 Potter Hill Road
• Manner of Death 0 Natural Cause Accident El Homicide Suicide D Undetermined ri Pending
✓ Circumstances Investigation
W Medical Certifier Name Title
Robert Sponzo MD
Address
Cancer Center, 102 Park St,Glens Falls,NY 12801
Death Certificate Filed District Number O Register Number
City, Town or Village Bolton Landing Bolton Landing5!pJ�
❑Burial Date Cemetery or Crematory
Pine View Crematorium
0 Entombment Address
®Cremation 21 Quaker Road,Queensbury,NY 12804
Date Place Removed
22 El Removal and/or Held
and/or Address
F Hold
N
O Date Point of
• rjTransportation Shipment
a by Common Destination
Carrier
E]Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Road,Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
i- Remains are Shipped, If Other than Above
a Address
D. Permission is hereby granted to dispose of the human re in descr'bed ye as inddii( ated.
Date Issued /0-07-20/5Registrar of Vital Statistics UQ��
� 511.$4JL(signature)
District Number 569 60 Place Bolton Landing
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILJ Date of Disposition Ip/q It) Place of Disposition ,�Jk✓ `tea(,...
W (address)
(section) /f t num r) (grave number)
pName of Sexton or Person in Charge of P emises G FIGJ evirrif
(plea print)
W Signature Title C1 Cirk►�d(L
(over)
DOH-1555(02/2004)