Malinconico, Mary NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
§. Name First Middle Last Sex
Mary Eileen Malinconico Female
a• ::, Date of Death Age If Veteran of U.S. Armed Forces,
January 20, 2012 64 War or Dates
Place of Death Hospital, Institution or
Z: City, Town or Village Glens Falls 1 Street Address Glens Falls Hospital
til
cli Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
t Medical Certifier Name Title
P Robert Sponzo MD
Address
'• 102 Park St. Glens Falls,NY
°' 1 Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 32
❑Burial Date Cemetery or Crematory
January 23, 2012 Pine View Crematory
❑Entombment Address
❑x Cremation Quaker Rd., Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
O and/or Address
Hold
N
O Date Point of
NTransportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
"°s Permit Issued to Registration Number
• Ha: Name of Funeral Home Regan& Denny Funeral Home 01443
Address
-:-::: 53 Quaker Road, Queensbury,NY 12804
., Name of Funeral Firm Making Disposition or to Whom
i-= Remains are Shipped, If Other than Above
2, Address
td
ttli
a
Permission is hereb granted to dispose of the human remains escribe above as in, . -d.
= Date Issued 0/ g �p/a- Registrar of Vital Statistics �/l7d _ . 37-(,.
(signature)
• :,; District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above w e disposed of in accordance with this permit on:
WDate of Disposition i/jLjlL Place of Disposition Pint()to: Cr::,:n-eforlti"-
L (address)
W
co
et (section) (lot numberk` (grave number)
Q liJName of Sexton or Person in Charge of Premises rtr Jehnd "
Z I (please print)
W Signature
:I-- Title CQ M f0Q,
9
(over)
DOH-1555(02/2004)