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Kamburelis, Stephen 4--) NEW YORK STATE DEPARTMENT OF HEALTH ,) ) �� Vital Records Section Burial Transitrermit Name First Middle Last Sex Stephen Michael Kamburelis i Male Date of Death Age If Veteran of U.S. Armed Forces, June 27, 2011 50 I War or Dates 1... Place of Death Hospital, InVitution or Z City, Town or Village Glens Falls Street Address Glens Falls Hospital pManner of Death n Natural Cause n Accident n Homidde Suicide Undetermined Pending W Circumstances Investigation w Medical Certifier Name Title CI `KC)b 4 4. Seprzo AID. Addres + 12eev v I O2-4 STeeE' , 6 leas. Icy 1 Zko 1 Death Certificate Filed District Number j Register Number City, Town or Village Glens Falls,NY 5601 , -2 FS' ❑Burial i Date Cemetery or Crematory D Entombment July 1, 2011 ( Pine View Crematory Address ©Cremation Quaker Road, Queensbury, NY 12801 Date Place Removed Z Removal and/or Held and/or Address �• Hold N 0 Date Point of NI I Transportation Shipment p by Common Destination Carrier n Disinterment Date Cemetery Address 1 I Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Regan& Denny Funeral Home 01464 Address 53 Quaker Road, Queensbury,NY 12804 Name of Funeral Firm Making Disposition or to Whom t— Remains are Shipped, If Other than Above 2 Address Ce C. Permission is hereby granted to dispose of the human remains describe bov s 'ndicated. Date Issued O/a / / Registrar of Vital Statistics ��Z :!/ (signature) District Number 5601 Place Glens Falls,NY I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z W Date of Disposition )/1 lit Place of Disposition „v 'lu.a rw.rifioraW.. W (address) N 0 (section) (-number) (grave number) QName of Sexton or Person in Charge of Premises r.s}I,Q.,.,- ,_ Mry(t W ,, 11 (Please print) Signature4 Title ((�1;d i UC (over) DOH-1555(02/2004)