D'Angelico, Gregg NEW YORK STATE DEPARTMENT OF HEALTH . s #/
Vital Records Section Burial - Transit�ermit
Name First Middle Last Sex
Gregg Anthony D'Angelico Male
Date of Death Age If Veteran of U.S. Armed Forces,
February 17, 2017 58 War or Dates
Place of Death Hospital, Institution or
w City, Town or Village Fort Edward Street Address 37 Ethan Allen Street
Manner of Death u Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ri❑ Pending
Lii
Circumstances Investigation
W Medical Certifier Name Title
John P. Stoutenberg, M.D. Dr.
Address
102 Park Street Glens Falls, NY 12801
Death Certificate Filed District Number Registeumber
City, Town or Village Fort Edward S753
❑Burial Date Cemetery or Crematory
February 21, 2017 Pine View Crematory
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
O and/or Hold Address
CO+ Date Point of
u., ❑Transportation Shipment
CO by Common Destination
O Carrier
❑ Disinterment Date Cemetery Address
❑ Re nterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home- FE 01079
Address
82 Broadway, Fort Edward NY 12828
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
X• ' Address
111
®. Permission is he eby anted to dispose of the human r- s described above as indi ted.
Date Issue ,4/ a p/ ) Registrar of Vital Statistic _ MCt(signature
,�
District Number�)53 Place �,��, � ,Uay/�
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
t u Date of Disposition 02/21/2017 Place of Disposition Quaker Road Queensbury,NY 12804 �;ne.V C,ttmiory
* (address)
iii
(section) (lot number) (grave number)
i Name of Sexton or Person in Charge of Premises J erM ;y S4,><iIrzs
(please print)
ill Signature Title LTCw+c Or
(over)
DOH-1555 (02/2004)