Columbetti, Patrick ley
NEW YORK STATE DEPARTMENT OF HEALTF< i 111
- Transit Permit
Vital Records Section
Name First Middle L Sex
Patrick N. umbetti Male
Date of Death Age If Veteran of U.S. A ed Forces,
March 13, 2013 60 War or Dates No
. PI ce of Death Hospital, Institution or
Cit Town or Village Glens Falls Street Address Glens Falls Hospital
0nner of Death X Natural Cause n Accident ❑Homicide ❑Suicide pi undetermined Pending
F Circumstances Investigation
y Medical Certifier Name Title
a Scott Biasetti Dr
Address
100 Park St., Glens Falls,NY 12801
D-- Certificate Filed District Number Register Number
/own or Village Glens Falls 5601 9 /
■ Burial Date Cemetery or Crematory
March 14, 2013 Pine View Crematory
❑Entombment Address
❑x Cremation Quaker Road, Queensbury, NY
Date Place Removed
ZO ❑Removal and/or Held
and/or Address
H Hold
Cl) _
O Date Point of
W ❑Transportation Shipment
p 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
1-- Remains are Shipped, If Other than Above
d Address
r
Ui
IL
Permission is hereby 7arti.7d to dispose of the human r mains escribed a dye as indicat d.
Date Issued (`� 1 Registrar of Vital Statistics �'f_Q���a si 'G re
(signature)
District Number 5601 Place Glens Falls / / 020/
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 3—J S-/3 Place of Disposition A 1'-it v-,g,,,/ 4`lf
L (address)
W
U)
IX
0 (section) (lot number) (grave number)
p Name of Sexton;o" Per n in C of Premises 0��. C{
Z // (please print)
W Signature / f3C%✓1 • Title ( >�"4s�
(over)
DOH-1555(02/2004)