Roccasecca, Salvatore NEW YORK STATE DEPARTMENT OF HEALTH I
Vital Records Section Burial - TranSit Hermit
Name First Middle Last Sex
Salvatore Roccasecca Male
Date of Death Age If Veteran of U.S. Armed Forces,
February 16, 2012 87 War or Dates
Place of Death Hospital, Institution or
ul City, Town or Village Glens Falls Street Address Glens Falls Hospital
CI Manner of Death a Natural Cause D Accident ❑ Homicide ❑ Suicide ❑ Undetermined El Pending
Circumstances Investigation
2 Medical Certifier Name Title
G't Gamal Khalifa, M.D. Dr.
Address
100 Park Street Glens Falls, NY 12801
Death Certificate Filed District Number 60 Regs�Num rr
City, Town or Village
❑Burial Date Cemetery or Crematory
February 21, 2012 Pine View Crematorium
❑Entombment Address ��
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed /---
❑ Removal
and/or Held
and/or Address
E Hold
N Date Point of
c❑Transportation Shipment
CO by Common Destination
CI Carrier
ElDisinterment Date Cemetery Address
Date Cemetery Address
❑ Reinterment
Permit Issued to Registration Number
: Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
i�-T Remains are Shipped, If Other than Above
Address
tr
Ui
,' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued �/j--2r/ Z Registrar of Vital Statistics ` �C; ,L � i,�( 4.1. .��ti
A 't, (signature
3 District Number 560 1 Place 6 ` vQ S co,"s, !v T
I certify that the remains of the decedent identified above were disposed of yin accordance with this permit on:
W Date of Disposition �b zii to1Z Place of Disposition
Re iVaw � ot,�
`' (address)
LU
CO.'
Ce (section) 4 , pot number)�~ (grave number)
a. Name of Sexton or Pers in Charge of remises (, r4 �p1*, `30%.yi-
L1 (please print)
Li Signature Title C12icn.a 411,
(over)
DOH-1555 (02/2004)