Marcantonio, Ben k.
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Ben A. Marcantonio Male
Date of 9ge If VeteraWar orn of DatesS. Armed Forces, /�` q/7 7 &
September 18, 2016
Place of Death Hospital, Institution or l�
City, Town or Village South Glens Falls Street Address 29 Spring Street
Manner of Death Natural Cause ❑ Accident ElHomicide ❑ Suicide ❑ Undetermined ri Pending
Circumstances Investigation
LLI Medical Certifier Name Title
CI John P. Stoutenberg, M.D. Dr.
Address
102 Park Street Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village South Glens Falls
J Burial Date Cemetery or Crematory
September 21, 2016 Pine View Cemetery
❑Entombment
Address
❑Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
and/or Address
_ Hold
0 Date Point of
a. ❑Transportation Shipment
by Common Destination
a Carrier
Date Cemetery Address
❑ Disinterment
Date Cemetery Address
III Reinterment
Permit Issued to Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home-SGF 01078
Address
136 Main Street, South Glens Falls NY 12803
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
le; Permission is hereby ranted to dispose of the human remain des ribed abo a indicated.
Date Issued 9l PI�►(p Registrar of Vital Statistics �
� (( / , / 4�sf nature)
District Number q y Place t/ /0 i( 5 so 6i'z s t- s
V
I
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 09/21/2016 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
Erie 6E 1
(section) (lot number) (grave number)
Name of Sext or Person in Charge of Premise Connie L. Go dPrt-
(please print)
a Si natur eri n nci nt
9 - K��QQ� Title Cemetery SuP i-
(over)
DOH-1555 (02/2004)