Arcuri, Albert NEW YORK STATE DEPARTMENT OF HEALTH 1 271
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Albert Arcuri Male
Date of Death Age If Veteran of U.S. Armed Forces,
May 21, 2015 89 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Fort Edward Street Address 14 Hillview Ave
Manner of Death Natural Cause illAccident ❑ Homicide El ❑ Undetermined ❑ Pending
Circumstances Investigation
Medical Certifier Name Title
Joseph C. Mihindu, M.D. Dr.
Address
52 Park St. Glens Falls, NY 12801
Death Certificate Filed District Number Register tuber
City, Town or Village Fort Edward 51.2 14
❑Burial Date Cemetery or Crematory
May 22, 2015 Pine View Crematory
0 Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment
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 h reby granted to dispose of the human ' s describecya ov as indicated.
Date Issued Registrar of Vital Statistics -'YY
(signature)
i i District Number 5755 Place 0 6J/�'L and
', I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
' ' Date of Disposition 05/22/2015 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
la-
(section) /4 (lot number) (grave number)
•
Name of Sexton or Person •n Charge of Premises I"r
(please print)
,_ Signature / 1,- Title ( icMiVJL
(over)
DOH-1555 (02/2004)