Costello Jr, Francis NEW YORK STATE DEPARTMENT OF HEALTH it g6-2
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Francis J Costello Jr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
11/03/2016 57 years War or Dates
P of Death Hospital, Institution or
Cit ILI , Tc (gf ( Glens Falls Street Address Park St Glens Falls, N Y
Finer of Death Natural Cause Accident 0 Homicide Suicide Undetermined Pending
ILI Circumstances Investigation
Id Medical Certifier Name Title
4
Address
iig
Death Certificate Filed District Number Register Number
MOM AGX0VX Glens Falls 5601 564
■Burial Date Cemetery or Crematory
11/09/2016 Pine View Cemetery
' : ❑Entombment Address
ig'Cremation Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
❑and/or
Address�;;
f
Hold
0 Date Point of
eL
Q Transportation Shipment
0 by Common Destination
Carrier
Q Disinterment Date Cemetery Address
::, Q Reinterment Date Cemetery Address
gi Permit Issued to Registration Number
gi Name of Funeral Home Wilcox & Regan Funeral Home 01821
< i Address
11 Alqonkin Street Ticonderoga, N Y
Name of Funeral Firm Making Disposition or to Whom
1_Remains are Shipped, If Other than Above
,2 Address
i
Ill
` Permission is hereby granted to dispose of the human r, 'sins described above as indica -d.
Date Issued 11/08/2016 Registrar of Vital Statistics �j C'
g � ��C--1(sign t�ire � •
qii
pi District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above wer_ disposed of in accordance with this permit on:
Z
ILI Date of Disposition ii/iD//k, Place of Disposition r,nttiv4_. &$I_J
' ii (address)
111
CC (section) (lot number) (grave number)
'i Name of Sexton or Person in Char a of Premises hi Se"NI'f
(please pnnt)
u,
4
Signature
Title MLA)MO
(over)
DOH-1555 (02/2004)