Russo Jr, Ralph NEW YORK STATE DEPARTMENT OF HEALTH f t
Vital Records Section xr "' Burial - Transit Permit
Vt Name First Middle Last Sex
Ralph J. Russo Jr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
2/7/1 5 87 War or Dates No
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls HOspital, GF, NY
Manner of Death Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined El❑ Pending
Circumstances Investigation
Medical Certifier Name Title
Michael Fuller MD
Address
ZUAN
100 Park Street, Glens Falls, NY 12801
' `� Death Certificate Filed District Number RegisterJuber
City, Town or Village Glens Falls 5601
0 Burial Date Cemetery or Crematory
rt 2/9/15 Pine View Crematory
❑Entombment
Address
ia:❑Cremation Quaker Road, Oueensbury, NY
IV Date � emoved
❑ Removal and/or Held
and/or Address
Hold
Date ` Point of
❑Transportation Shipment
by Common Destination
Carrier
❑ Disinterment
Date Cemetery Address
I I Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home 0 T 0 7 8
ifite Address
136 Main St. Argyle, NY 12801
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby ranted to dispose of the human remains described b v asi icat
Date Issued 0 09 LU15�:Registrar of Vital Statistics /'v� GEC u
(signature)
a District Number 5601 Place Glens Falls, NY
X
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 2110 I IT' Place of Disposition (, \L C .taL,
(address)
(section) (lot tuber) (grave number)
Name of Sexton or Perso in Charge of Premises a,4 1) .- SOO*
(please p t)
Signature Title Onow2
(over)
DOH-1555 (02/2004)