Scarselletta, Elilzabeth NEW YORK STATE DEPARTMENT OF HEALTH t ), Burial - Transit Permit
Permit
Vital Records Section
_. Name First Middle Last Sex
Elizabeth Scarselletta Female
Date of Death Age If Veteran of U.S. Armed Forces,
February 18, 2017 83 War or Dates
-I Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address 22 F Hartford Ave
Manner of Death D Natural Cause 0 Accident 0 Homicide Suicide 0 Undetermined 0 Pending
Investigation
�; Medical Certifier Name Title
et
Anthony Petracca, Dr.
Address
3 Irongate Center Glens Falls, NY 12801
Death Certificate Filed District Number Register \l miler
`" City, Town or Village Glens Falls ��44 // //
0 Burial Date Cemetery or Crematory
February 24, 2017 Pine View Crematory
.';L i Entombment
Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
0 Removal and/or Held
and/or Address
Hold
Date Point of
0 Transportation Shipment
by Common Destination
Carrier
Es Eil Disinterment Date Cemetery Address
r Reinterment Date Cemetery Address
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
tt Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains des ri ed b ve n icated.
Date Issued � �/2Dj7 Registrar of Vital Statistics i�, SG,
(signature)
District Number 60/ Place ,>/„4A„ _./Z
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 02/24/2017 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) /.(lot number) (grave number)
Name of Sexton or Person in Charge of Premises h r% akir Stm+n l k
(plea print)
Signature !rt -4 Title (WI PI Pa--
-,.......
(over)
DOH-1555 (02/2004)