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Stipano, John 2. NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex John Anthony Stipano Male Date of Death Age If Veteran of U.S. Armed Forces, February 11, 2017 81 War or Dates I Place of Death Hospital, Institution or Ww City, Town or Village Glens Falls Street Address Glens Falls Hospital a Manner of Death 0 Natural Cause ❑ Accident ❑ Homicide ElSuicide ❑ Undetermined El Pending Ili Circumstances Investigation tol tij Medical Certifier Name Title a. Paul Paul F. Bachman, Address 3767 Main Street Warrensburg, NY 12885 Death Certificate Filed District Number )) Register Number City, Town or Village Glens Falls 5 u 0 ( t 0 6 ❑Burial Date Cemetery or Crematory February 15, 2017 Pine View Crematory ❑Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed ElRemoval and/or Held and/or Address E Hold CO Date Point of • ❑Transportation Shipment gt by Common Destination 0 Carrier Date Cemetery Address ❑ Disinterment Date Cemetery Address El Reinterment 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 Address w Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued .Z G. 11-5 ) / 6 Registrar of Vital Statistics JJry-p w�n. f 1 i (signature) District Number 56 0 i Place C (S2�S 4 \S CVeJ I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z to Date of Disposition 02/15/2017 Place of Disposition Quaker Road Queensbury,NY 12804 ?,y,e vh'e,)Cie/eta, (address) in OA LC (section) (lot n mber) (grave number) 8 Name of Sexton o in Cbiarge of Premises J IA-1 isam .c.._vri 4"-4 he_ j,( (please print) w Signature �i �-- Title C -h'1 e,-10(y 01 ef-:, K- e; (over) DOH-1555 (02/2004)