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Pilino, Antonio
L O +N OF QUEEVBU9�y PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 , Funeral Director �,' I Cox Name ►`I ✓1 '� pr;O �% lkhn Case# �OS Date Of Cremation U— as_ oZDO3 Time Cremation Started 1 ; u,� �� ►�'� Time Cremation Completed pQ � Type of Container ,If �� f ' ,Sa Remarks �� e ry1 vim' ; w p m f o f��'► 04/24/2003 13:40 - 5185854475 WILCOX REGAN PAGE, 01 NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Perthit Name First Middle Last Male Antonio Date of Death Age if Veteran of U.S.Arm Forces, 4/21/2003 86 yrs. War or Dates No Place of Death Hospital, Institution or City.Town or Village Town of Hague Street Address 9051 Lake Shore Drive Manner of Death®Natural Cause Accident Homicide Suicide Undetermined Pending Circumstances Investigation Medical Certifier Name Title Glen Chapman M.D. Address P.O. Box 291 Ticonderoga, New York 12863 Death Certificate Filed District Number Registe umber C ,Town or Vil a Tovn of Hague 5653 Date etery or Crematory C1Buriai 4/24/2003 Pine View Crematory Address ®Cremation Queenebury, New York Date , Place Removed El Removal and/or Held and/or Address Hold Date Point of �]Transportation Phi ment by Common Destination Carrier Disinterment Date Cemetery Address Q ReintsrmeM Date Cemetery Address Permit Issued to Registration Number aR Name of Funeral Home Wilcox & Regan Funeral Home 01983 Address : R 11 Algonkin St. , Ticonderoga, New York 12883 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Address Parmission Is hereby granted to dispose of the human remains described above as ndi ted. Date Issued 4/24/2003 Registrar of Vital Statisti rl sig� tore) District Number l'S'66 3 Place 41 I certify that the remains of the decedent identified above were disposed of in accordance with this permit on. Date of Disposition L1-o15-2bn3 Place of Disposition (address) (section) (lot number) (grave number) Name of Sexton or P son in Charge of Premises `T;w,o h, �p �Q ✓� (please print Signature TitleCr-e rh�v©i` DOH-1555 (10/89) p. 1 of 2 VS-61