Brukilacchio, Margarita E. Ross 1� S32
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Margarita E Ross-Brukilacchio Female
Date of Death Age If Veteran of U.S.Armed Forces,
05/05/2020 82 Years War or Dates
Place of Death Hospital,Institution or
WCity,Town or Village Queensbury Town Street Address The Stanton Nursing And Rehabilitation Centre
p Manner of Death Q Natural Cause ElAccident Homicide Suicide Undetermined Pending
W Circumstances Investigation
W Medical Certifier Name Title
0 Wendy Steinhacker PA
Address
152 Sherman Ave,Queensbury Town,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Queensbury 5657 95
Burial Date Cemetery,Crematory or Facility Name
05/06/2020 Pineview Crematory
Entombment Address
0 Cremation Queensbury Town,New York
❑Donation
Z Removal Date Place Removed
and/or and/or Held
0 H Hold Address
N
O
(L Date Point of
N FITransportation Shipment
p by Common
Carrier Destination
Disinterment
Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Densmore Funeral Home Inc 00448
Address
7 Sherman Ave,Corinth,New York 12822
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped,If Other than Above
Address
Q
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 05/06/2020 Registrar of Vital Statistics Caroline Hildegarde Barber(Electronically Signed)
(signature)
District Number 5657 Place Queensbury, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: `
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WDate of Disposition ''r�7��� Place of Disposition ,*.u„i
LU (address)
W
t) (section) /lot number (grave number)
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Name of Sexton or Person in Charge of P mises r'}
Z (pl se pnn
W Signature Title Of 1
DO H-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) 01 130 7
t
Receipt
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Human remains of F delivered on , 20
1
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#