Grillo, Natale NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Natale Grillo Male
Date of Death Age If Veteran of U.S. Armed Forces,
02/05/2018 95 Years War or Dates
Place of Death Hospital, Institution or
City, Town or Village Granville Village Street Address Indian River Rehabilitation And Nursing Center
Manner of Death gi Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined El❑Pending
Circumstances Investigation
Medical Certifier Name Title
Sean Bain MD
Address
17 Madison St,Granville Village,New York 12832
Death Certificate Filed District Number Register Number
City, Town or Village Granville Village 5725 4
❑Burial Date Cemetery or Crematory
02/08/2018 Pine View Crematory
❑Entombment Address
Cremation Queensbury, New York
Date Place Removed
❑Removal and/or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment
by Common Destination
Carrier
❑Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 02/06/2018 Registrar of Vital Statistics riiclari o6erts(f(ectronicafySigned)
(signature)
District Number 5725 Place Granville Village, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition l j$jtg Place of Disposition i.,c •.,r t&.„o-oe._•
(address)
(section) n J(lot numb , (grave number)
Name of Sexton or Person in Charge of Premises t.��
lease print)
Signature �i�'1 Title fkf TO(L
(over)
DOH-1555 (02/2004)