Juliano, III. William NEW YORK STATE DEPARTMEN F HEALTH 4 a/ 1
Vital Records Section , Burial - Transit Permit
Name First le Last Sex
William Juliano,III Male
Date of Death Age \If Veteran of U.S. Armed Forces,
6/22/2018 Y_ �µ !, War or Dates
E_ Place of Death ospital, Institution or
Z City, Town or Village Queensbury Street Address 22 River Street
pManner of Death ❑X Natural Cause ❑Accident Homicide ❑Suicide ❑Undetermined ❑Pending
VCircumstances Investigation
W Medical Certifier Name Title
O Michael Adams,MD
Address
1448 State Rt.9 South Glens Falls,NY 12803
Death Certificate Filed District Number lIii ier Number
City, Town or Village Queensbury 5657
❑Burial Date Cemetery or Crematory
❑Entombment June 25,2018 I Pine View Crematory
Address
®Cremation Quaker Road, Queensbury,NY 12804\
Date Place Rem ved
Z ❑Removal and/or Held
9 and/or Address
H Hold
CO Date Point of
N ❑Transportation Shipment
p by Common Destination
Carrier
n Disinterment Date Cemetery Address
n Renterment Date Cemetery Address
I
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford 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
iL
W ,
O.
Permission is hereby granted to dispose of the human remains descri ed above as indicated.
Date Issued Q(� I lc( Registrar of Vital Statistics C C. 11----
(signature)
District Number 5657 Place Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
iii Date of Disposition I,ii'.d li¢_ Place of Disposition LU.. .`a
(address)
W
co
rL (section) lot number) (grave number)
pName of Sexton or Person in Charge of Premises h,,t _ So-.)r4-
Z (ple a print)
uu
Signature Title d RI..
(over)
DOH-1555(02/2004)