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Cozzolino, Anna
�F 8►a NEW YORKSTATE DEPARTMENT OF HEALTH 1 Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Anna Cozzolino Female Date of Death Age If Veteran of U.S.Armed Forces, 12/03/2019 65 Years War or Dates Place of Death Hospital,Institution or WCity,Town or Village Long Lake Town Street Address 2179 Tupper Road, Long Lake Town, New York 12847 p Manner of Death Natural Cause Accident Homicide Suicide Undetermined ©Pending W Circumstances Investigation V W Medical Certifier Name Title 13 Virginia Jennings Coroner Address P.O. Box 7,Long Lake, New York 12847 Fi ath Certificate Filed District Number Register Number ty,TownorVillage Long Lake 2056 10 Burial Date Cemetery,Crematory or Facility Name 12/06/2019 Pine View Crematory Entombment Address RiCremation Queensbury Town, New York ❑Donation OZ Removal Date Place Removed and/or and/or Held 1-N Hold Address O d Date Point of N Transportation Shipment p by Common Carrier Destination Disinterment Date Cemetery Address JE]Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Miller Funeral Home 01199 Address 6357 Nys Rte#30, Indian Lake, New York 12842 Name of Funeral Firm Making Disposition or to Whom H Remains are Shipped,If Other than Above Address W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 12/06/2019 Registrar of Vital Statistics DbdeLe9L6b"(E16cfro!cai1y9gW (signature) District Number 2056 Place Long Lake, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: ll Z Date of Disposition 12 Place of Disposition W (address) 2 W N (section) ( number) (grave number) Name of Sexton or Person in Charge of Premises (please rint)Z W Signature Title DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) 01.3139 Receipt Human remains of delivered on ', 20 f'/ j Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#