Trunzi, Michael NEW YORK STATE DEPARTMENT OF HEALTH # 313
Vital Records Section - - 1 Burial - Transit Permit
7-7
Name First Middle Last Sex
t. Michael Trunzi Male
':: Date of Death Age If Veteran of U.S. Armed Forces,
May 11, 2015 82 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
at-. Manner of Death Q Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
Medical Certifier Name Title
a Mathew Varughese, M.D. Dr.
Address
$1 100 Park Street Glens Falls, NY 12801
Death Certificate Filed District Number -.A Registe l`y� r
`' -' - City, Town or Village Glens Falls ( ,
R 0 Burial Date Cemetery or Crematory
May 12, 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
CAi' ❑Transportation Shipment
aff by Common Destination
Carrier
❑ Disinterment Date Cemetery Address
':❑ 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 hereb granted to dispose of the human remains descr' e a o ss` i i d.
Date Issued OS/2/2oiS Registrar of Vital Statistics L�`
(signature)
District Number 6-6:2O/ Place 7f4 . ,/A, it-7/
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
.
r' Date of Disposition 05/12/2015 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
1.
(section) /' (lot number) (grave number)
Name of Sexton or Personin Charge of Premises `�'% ,+
r ( ease print)
Signature Title mfilliT�L
9 17`�dv ''t.
(over)
DOH-1555 (02/2004)