Mucci, Daniel •
Z,O
NEW YORK STATE DEPARTMENT OF HEALTH t' _
Vital �Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Daniel A. Mucci Male
Date of Death Age If Veteran of U.S. Armed Forces,
04/17/2015 82 years War or Dates
Place of Death Hospital, Institution or
City, TdOIXXr MOWGlens Falls Street Address Glens Falls Hospital
Manner of Death Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
W Medical Certifier Name Title
Kyle S Leonard M D
Address
161 Carey Road, Queensbury, N Y 12804
Death Certificate Filed District Number Register Number
City, Tdl 4X&MOO Glens Falls 5601 211
❑Burial Date Cemetery or Crematory
04/20/2015 Pine View Cemetery
Entombment Address
(Cremation Queensbury, NY 12804
Date Place Removed
C ❑Removal and/or Held
and/or Address
F=` Hold
C3 Date Point of
iTransportation Shipment
2-1 by Common Destination
Carrier
ID Date Cemetery Address
❑Reinterment Date • Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Chase-smith Family Funeral Home 00490
Address
319 Park Ave. Mechanicville, N Y 12118
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
U
Permission is hereby granted to dispose of the human remains desc ibbedjab° a as" ' ated.
Date Issued 04/20/2015 Registrar of Vital Statistics G Bra 1"
(signature)
District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
tLI Date of Disposition Place of Disposition e,t _, ^'i
(address)
UI
i'
CC (section) (lot numb ) (grave number)
pName of Sexton or Person in Charge of Premises '* '�
/(please print)
Signature y- Title ritCio tet
(over)
DOH-1555 (02/2004)