DeSimone, Marino NEW YORK STATE DEPARTMENT OF HEALTH 4 rt;
Vital Records Section Burial - Transitermit
Name First Middle Last Sex
Marino Bruno DeSimone Male
Date of Death Age If Veteran of U.S. Armed Forces,
May 2, 2013 83 War or Dates Korea
Place of Death Hospital, Institution or
City, Town or Village Argyle Street Address Pleasant Valley
Manner of Death Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
Medical Certifier Name Title
Edit Masaba, MD Dr.
Address
200 Main Street Greenwich, NY 12834
Death Certificate Filed District Number �..- Register Number,
" City, Town or Village Argyle LL/1ff
0 Burial Date Cemetery or Crematory
May 3, 2013 Pine View Crematory
,5❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
and/or Address
E Hold
th Date Point of
❑Transportation Shipment
by Common Destination
Carrier
❑ Disinterment Date Cemetery Address
Date Cemetery Address
❑ Reinterment
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home 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
i
Permission is hereby ranted to dispose of the human re ins described above as indicated.
Date Issued 6 lc)
r 3 Registrar of Vital Statistics A + 1Ij,f,A ¢ yyv
(signature)
District Number '—f Place I V (k _I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 05/03/2013 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) /f , (lot number) (grave number)
Name of Sexton or Pers n in Charge f Premises9 a Q
Ilease print)
Si nature la— Title CW" 0It
(over)
DOH-1555 (02/2004)