Costantino, Anthony NEW YORK STATE DEPARTMENT OF HEALTH ' ®3
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Anthony Costantino Male
Date of Death Age p If Veteran of U.S.Armed Forces,
I. June 1, 2016 War or Dates
2 Place of Death (( Hospital, Institution or q DA v/5 5%/�e e T
W City,Town,or Village Whitehall Street Address Residence
0 Manner of Death FA Natural Cause El Accident Ell Homicide El Suicide n Undetermined El Pending
W Circumstances Investigation
U Medical Certifier Name Title
W Dr. Aqeel Gillani, M.D. Dr.
a Address
102 Park Street, Pruyn Pavilion, Glens Falls, NY 12801
Death Certificate Filed District Number ��� , Register Number
City,Town or Village Whitehall
❑Burial Date Cemetery or Crematory
June 3, 2016 Pineview Crematorium
❑Entombment Address
n Cremation 21 Quaker Road Queensbury, NY 12804
Date Place Removed
0 n Removal and/or Held
a. and/or Address
111 Hold
0 `Date Point of
0 Ej Transportation Shipment
D. by Common Destination
Carrier ,
Date Cemetery Address
6 0
Disinterment
n Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Jillson Funeral Home, Inc. 00885
Address
46 Williams Street, Whitehall, New York 12887
I- Name of Funeral Firm Making Disposition or to Whom
2 Remains are Shipped, If Other than Above
X
W Address
a
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued (P-a-)G'7 b Registrar of Vital Statistics ( 0 122%r!/ _
(signature)
District Number S'(716 Place Whitehall,New York
P I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2
W Date of Disposition 06/03/2016 Place of Disposition Pineview Crematorium
2 (address)
W
Y)
0 (section) Arcof number) (grave number)
00 Name of Sexton or Person in Charge of Premises ► S
W (pleaL.se print)
Signature el_ Title ( p�
(over)
DOH-1555 (02/2004)