DelSignore, Andrew It
NEW YORK STATE DEPARTMENT OF HEALTH - Transit emit
Vital Records Section Burial
Name First Middle Last Sex
Andrew M. DelSignore Male
Date of Death Age If Veteran of U.S. Armed Forces,
August 12,2013 83 War or Dates 1954- 1954
Place of Death Hospital, Institution or
Z City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death[}Natural Cause p Accident Homicide Suicide Undetermined �Pending
Circumstances Investigation
C.)
W Medical Certifier Name Title
G Elizabeth Hutchins
Address
2 Broad St Plaza,Glens Falls,NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 3,5 I
❑Burial Date Cemetery or Crematory
August 16,2013 Pine View Crematory
0 Entombment Address
®Cremation Quaker Road, Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
IL' Hold
N
O Date Point of
N []Transportation Shipment
in by Common Destination
Carrier
[]Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Road,Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
I- Remains are Shipped, If Other than Above
2 Address
0-
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued d 1 I i 3 Registrar of Vital Statistics 1_,QC—y-.p
(signature)
District Number 5601 Place Glens Fallss y
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
• Date of Disposition 060 0 Place of Disposition 4,0 J
(address)
N
(section) (lot number) C (grave number)
Q Name of Sexton or Person in Charge of Premises )r,j 1A.4
(please print)
W Signature Title CQ 14-TO(L
(over)
DOH-1555(02/2004)