Arno, David i I
NEW YORK STATE DEPARTMENT OF HEALTH z 3
Vital Records SectionN.. Burial - Transit Permit
Name First Middle Last Sex
David D Arno Male
Date of Death Age If Veteran of U.S. Armed Forces,
05/09/2011 51 years War or Dates
-i. PI a of Death Hospital, Institution or
,,; .Cit Towbetkikviboc Glens Falls Street Address Park St Glens Falls, N Y 12801
Manner of Death 1 fyatural Cause Accident 0 Homicide Suicide Undetermined Pending
3a Circumstances Investigation
la Medical Certifier Name Title
DarciA Gaiotti-gnibbs M D
Address
102 Park St Glens Falls, N Y 12801
Death Certificate Filed District Number Register Number
iiiig t ow� iIXX Glens Falls 5601 213
Burial Date Cemetery or Crematory
❑Entombment 05/10/2011 I Pineview Crematory
Address
Ocjemation Queensbury, N Y 12804
Date Place Removed
Z n Removal and/or Held
� and/or Address
Hold
Date Point of
ti Q Transportation Shipment
d by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Q Reinterment Date - Cemetery Address
iiil Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home 01097
Address
136 Main Street South Glens Falls, N Y 12803
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address .
Lu
cL
Permission is hereby granted to dispose of the human ains described bove as Ind' ated
Date Issued 05/10/2011 Registrar of Vital Statistics X -7 ‘727--e
(signature)
District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above we e disposed of in accordance with this permit on:
2
ilf Date of Disposition 5-it-tk Place of Disposition Pink°10,,,, Cri,Kt.t4fiVi .
(address)
Ui
Crit
CC (section) (lot number) �'` (grave number)
Name of Sexton or Person in Cha a of Premises 1. L r-S Ili- ..fi t�+h t
`/i (ple6se print)
141..4 Signature G '� — Title COL IATO !C
(over)
DOH-1555 (02/2004)