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Stancampiano, Moss NEW YORK STATE DEPARTMENT OF HEALTH 1 • e N p I / Vital Records Section Burial - Transit Permit Name First Middle Last Sex Moss Stancampiano Male Date of Death Age If Veteran of U.S. Armed Forces, October 21, 2015 36 War or Dates Place of Death Hospital, Institution or City, Town or Village Street Address Manner of Death❑ Natural Cause ❑ Accident ❑ Homicide 0 Suicide ❑ Undetermined X❑ Pending a Circumstances Investigation �' Medical Certifier Name Title Timothy Murphy, L©c o ‘cf- Address 52 Haviland Ave Glens Falls, NY 12801 Death Certificate Filed District Number ��r` Register1.um ber V City, Town or Village ("� `-1 ❑Burial Date Cemetery or Crematory October 23, 2015 Pine View Crematory ��❑Entombment Address ®Cremation Quaker Road Queensbury,NY 12804 Date Place Removed Removal and/or Held ❑ and/or Address Hold Date Point of ❑Transportation Shipment by Common Destination Carrier Date Cemetery Address El Disinterment I Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home M. B. Kilmer Funeral Home- FE 01079 Address 82 Broadway, Fort Edward NY 12828 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Address Permission is hereby granted to dispose of the huma remains d cribed alove as indi :ted'. Date Issued Jo/ J j�Registrar of Vital Statistics / 1Q rce_P-41/�(signnaature) District Number r(p0 Place . ! ` _-'E J J certify that the remains of the decedent identified above were disposed of in accordant with this permit on: �. Date of Disposition 10/23/2015 Place of Disposition Quaker Road Queensbury,NY 12804 (address) lli CO I Z (section) if/ (lot number (grave number) aName of Sexton or Person in Charge of Premises G/�rf 3II ,f lease print) W Signature G� l Title 6264 (over) DOH-1555 (02/2004)