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LiCausi, Robert iir NEW YORK STATE DEPARTMENT OF HEALTH r),1 Vital Records Section Burial - Transit Permit Name First Middle Last Sex Robert Bruce LiCausi Male Date of Death Age If Veteran of U.S. Armed Forces,February 24, 2018 67 War or Dates 1 Ini- I qt 1 I Place of Death Hospital, Institution or City, Town oF-Vifiege Moreau Street Address 24 Ella Drive Manner of Death IL.]Natural Cause ❑ Accident ❑ HOmicide ❑ Suicide ❑ Undetermined ❑ Pending Circumstances Investigation tit Medical Certifier Name Title a' Agee!A. Gillani, M.D. Dr. Address 102 Park Street Glens Falls, NY 12801 Death Certificate Filed District Njjrnb Register Number City, Town or Village Moreau44-444, `f 5(� �? itt❑Burial Date Cemetery or Crematory February 26, 2018 Pine View Crematory 4.q4.,544❑Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed ❑ 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-SGF 01078 Address 136 Main Street, South Glens Falls NY 12803 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 r • describe ab v s indicated. Date Issued at ob/ Registrar of Vital Statistics 111„"`7 1 (signature) District Number 1 J� Place � �— 35( d1 S4// i � (� ` por7JF / I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition 02/26/2018 Place of Disposition Quaker Road Queensbury,NY 12804 (address) ce (section) (lot numbet) (grave number) Name of Sexton or Person in Charge of Premises t ^E bJL 1t (tease print) Signature Title 'M (over) DOH-1555 (02/2004)