Cumoletti, Levi t
. 4
NEW YORK STATE DEPARTMENT OF HEALTH NEW
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Levi Hudson Cumoletti Male
Date of Death Age If Veteran of U.S. Armed Forces,
04 / 09 / 2017 7hrs 29 m War or Dates N/A
}= Place of Death Hospital, Institution or
WCity, Town or Village Glens Falls Street Address Glens Falls Hospital
Q Manner of Death®Natural Cause E Accident 0 Homicide E Suicide �Undetermined �Pending
W. Circumstances Investigation
la Medical Certifier Name Title
Ct Karen McShane MD
Mi Address
90 South St, Glens Falls, NY 12801
Death Certificate Filed District Number 5la DO Regist t(V im r
City,Town or Village Glens Falls
OBurial Date Cemetery or Crematory
04 / 11 / 2017 Pine View Crematory
8 Entombment Address
OCremation Queensbury, NY
"" Date Place Removed
Removal and/or Held
and/or Address
Hold
W. Date Point of
Q Transportation Shipment
by Common Destination
iiiig Carrier
' : ❑Disinterment Date Cemetery Address
0 Renterment Date Cemetery Address
:MiPermit Issued to Registration Number
Name of Funeral Home Compassionate Funeral Care 00364
Nii Address
402 Maple Ave. , Saratoga Sp., NY 12866
Mi Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
flf
�' "` Permission is hereby granted to dispose of the human rerfsins de cribed above as indicat6d.
Date Issued p /I /1 Registrar of Vital Statistics p `-2lsll�f'
7 .
/ gnature)
liig District Number25,Q / Place Glens Falls , New York
" I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z l Date of Disposition q ji3 ill Place of Disposition efi�n
euhu,., matter:
(address)
iiii
CC (section) /, (lot number) (grave number)
0 Name of Sexton or Person ip Charge of Premises G �� SV%Ant
Z (Abase print) •
i Signature A �i.s, Title / mINRI-
(over)
DOH-1555 (02/2004)