Leone, Adeline . a
.. 4 78b
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Adeline Elizabeth Leone Female
Date of Death Age If Veteran of U.S. Armed Forces,
09/27/2018 93 Years War or Dates
I— Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death J Natural Cause ❑Accident ❑Homicide El Suicide ❑Undetermined ❑Pending
Circumstances Investigation
W Medical Certifier Name Title
0 Sean Campanie NP
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
w ..
City, Town or Village Glens Falls 5601 463
❑Burial Date Cemetery or Crematory
10/01/2018 Pine View Crematory
"'Entombment
Address
®Cremation Queensbury Town, New York
Date Place Removed
Q❑Removal and/or Held
,�... and/or Address
H Hold
CA
0 Date Point of
tit❑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-South Glens Falls 01078
Address
136 Main St,S Glens Falls,New York 12803
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
wAddress
i'r�
i" Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 09/28/2018 Registrar of Vital Statistics co6ertia Curtis(Efectronica/TySigned)
(signature)
District Number 5601 Place Glens Falls, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition /0 II f r f Place of Disposition ,Alit, . j tf�
iiddress)
al
ix (section) (lot num rbA) (grave number)
0 Name of Sexton or Person in Charge of Premises 1 t'4rc— S 4„Ate.
(please print)
7 Signaturea I Title attAtbn
(over)
DOH-1555 (02/2004)