Scavo, Albert NEW YORK STATE DEPARTMENT OF HEALTH `L16
Vital Records Section Burial - Transit Permit
iliiiili Name First Middle Last Sex
ALBERT G. SCAVO MALE
iin Date of Death Age If Veteran of U.S. Armed Forces,
03/09/12 66 War or Dates
-: Place of Death Hospital, Institution or
City, Town or Village NORTH ELBA Street Address AMC-LAKE PLACID
tti Manner of Death Undetermined Pending
Cause �Accident ❑Homicide ❑Suicide ❑ ❑
Iii Circumstances Investigation
ig Medical Certifier Name Title
C. FRANCIS VA.R( A, MD
Address
PO BOX 76r LAKE PLACID, NY 12946
Death Certificate Filed District Number Register Number
City, Town or Village NORTH ELBA 1560
di❑Burial Date Cemetery or Crematory
3/14/12 pine view crematory
❑Entombment Address
in ECremation GLENS FALLS, NY
Date Place Removed
z Removal and/or Held
14❑and/or Address
�F;;
W
• Hold
fl Date Point of
D" Transportation Shipment
L3 by Common Destination
Carrier
❑Disinterment Date Cemetery Address
Sili ❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M. B. CLARK, INC 01075
Address
2310 SARANAC ANE. , LAKE PLACID, NY 11.9,41c
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
LEI
fl" Permission is hereby granted to dispose of the human rema. s described above as indicated.
Date Issued 0 3/11/12 Registrar of Vital Statistics J(,1 itia, �,bi I
(signatVre)
District Number 1560 Place /660,v or 1V --/ E U3/9
I- I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
ILI Date of Disposition 3-j(,- , Place of Disposition l l`►e eh°e1/4r (re, 4 L-:um
2 (address)
ili
fil
re
(sec" (lot number) (grave number)
Name of Sexton or Person in Char e of Premises Ir'hi o� NVrtelle
Z ��� /� (please print
iii
t Signature .1,�. i2 Title _Creep)a'�67 pSS-r
(over)
DOH-1555 (02/2004)