Grillo, Carmela NEW YORK STATE DEPARTMENT OF HEALTH if. 6
Vital Records Section Burial - Transit Oermi t
{ Name First Middle Last Sex
�r-r' Carmela
,;:gym Grillo Female
Date of Death Age- If Veteran of U.S. Armed Forces,
, February 3, 2016 92 War or Dates n/a _
f,r
', Place of Death Hospital, Institution or
r City, Town or Village Queensbury Street Address 79 Haviland Road
-, Manner of Death in Natural Cause I I Accident n Homicide n Suicide Undetermined n Pending
,0,- Circumstances Investigation
r Medical Certifier Name Title
o Dr.Gerald Abess,MD _
` Address
r Glens Falls,NY
/ Death Certificate Filed District Number R gter Number
City, Town or Village Glens Falls, NY 5657
�, Y 9
❑Burial Date Cemetery or Crematory
February 5, 2016 Pine View Crematory
❑Entombment Address
❑x Cremation Quaker Road, Glens Falls, NY 12804
Date Place Removed
ZZ 0 Removal and/or Held
and/or Address
H Hold
U)
O Date Point of
N ❑Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Ti Renterment Date Cemetery Address
' l Permit Issued to Registration Number
*A Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
x
0I Address
*.; 407 Bay Road, Queensbury,NY 12804
g,• Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
„,s• Permission is hereby granted to dispose of the hum.an_remains described ab e as indicated.
-,r', j
�� Date Issued��-r l�l co Registrar of Vital Statistics i 6 Z,� ��/ s�
f (signature)
r District Number Place
=r� ���� Town of Queensbury,NY 12804
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
ILI Date of Disposition.—S—K Place of Disposition 9;r i-tv C2ww{orY
Ill (address)
N
CC (section) . (lot number) (grave number)
ci Name of Sexton or Person in Charge of Premises UP.Cv y ctk =t'%*S
Z (please print)
tu
Signature 44 46..,f Title C.1ew►a10(
(over)
DOH-1555(02/2004)