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DeCamilla, Angela Rose NEW YORKSTATE DEPARTMENT OF HEALTH 4 i 213 Bureau of Vital Records Burial - Transit Permit : Name First Middle Last Sex Angela Rose DeCamilla Female Date of Death Age If Veteran of U.S.Armed Forces, 03/07/2020 95 Years War or Dates Place of Death Hospital,Institution or City,Town or Village South Glens Falls Village Street Address 47 Harrison Avenue,South Glens Falls village,New York 12803 Manner of Death © Natural Cause Accident Homicide Suicide Undetermined El Pending Medical Certifier Name Title Circumstances Investigation David Cunningham MD Address 3 Irongate Center,Glens Falls,New York 12801 Death Certificate Filed F4524 istrict Number Register Number City,Town or Village South Glens Falls Village 4 Burial Date Cemetery,Crematory or Facility Name 03/10/2020 Pine View Crematory -_ Entombment Address "el ©Cremation Queensbury Town,New York Donation Removal Date �an Removed Nand/or r Held Hold Address Q ❑Transportation Date Point of 1!2by Common Shipment Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home M B Kilmer Funeral Home-South Glens Falls 01078 =' Address 136 Main St,S Glens Falls,New York 12803 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped,If Other than Above Address W Permission is hereby granted to dispose of the human remains described above as indicated. Date issued 03/09/2020 Registrar of Vital Statistics Shannon 4gCCeher(EfectronicalTySigned) E (signature/ District Number 4524 Place South Glens Falls Village, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition I 1 Zo Place of Disposition (address) (section) (/otnumber) /grave number/ Name of Sexton or Person in Charge Premises c, (/ease print Signature Title f� DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) "' 1„ 14 0 9 Receipt Human remains of delivered on , 20 .Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#