Imperato, Katelyn Nicole h
NEW YORK STATE DEPARTMENT OF HEALTH "' Burial - TransitPermit
Bureau of Vital Records
Name First Middle Last Sex
Katelyn Nicole Imperato Female
Date of Death Age If Veteran of U.S.Armed Forces,
05/14/2021 31 Years War or Dates
F Place of Death Hospital,Institution or
Z City,Town or Village Moreau Town Street Address 14 Astoria Avenue,Moreau Town,New York 12803
p Manner of Death ❑Natural Cause 0 Accident 0 Homicide 0 Suicide El Undetermined ❑X Pending
Circumstances Investigation
W Medical Certifier Name Title
0 David DeCelle Coroner
Address
40 McMaster Street,Ballston Spa,New York 12020
Death Certificate Filed District Number Register Number
City,Town or Village Moreau 4562 25
Burial Date Cemetery,Crematory or Facility Name
05/19/2021 Pine View Crematory
Entombment Address
X❑Cremation Queensbury Town,New York
Donation
0 Removal Date Place Removed
and/or and/or Held
H Hold Address
0
d. Date Point of
(A j Transportation
p by Common Shipment
Carrier Destination
0 Disinterment
Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D Baker Funeral Home 01130
Address
11 Lafayette St,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
F Remains are Shipped,If Other than Above
Address
CC
ILi
C" Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 05/18/2021 Registrar of Vital Statistics LeeannMcca6e(E/?ctronicallySigner'
(signature)
District Number 4562 Place Moreau, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit n:
2
W Date of Disposition SI Zp Z( Place of Disposition �� �c.t'`
2 (address)
W
rA (section) 4 (lot number) (grave number)
G NIA
Name of Sexton or Person in Charge of Pre s r't "� �'�^
(pleasrint)
Signature
Title � C N
g
DOH-1555(07/18)pi of 2
Public Health Law Sec. 4145(2b) i ,".4 8 0 1
Receipt
Human remains of �r`f delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#