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Giambrone, Kevin James ./ , IIi1$ NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Kevin James Giambrone Male Date of Death Age If Veteran of U.S.Armed Forces, 09/07/2021 47 Years War or Dates Place of Death Hospital,Institution or Ili• City,Town or Village Glens Falls Street Address Glens Falls Hospital uQ Manner of Death © Natural Cause 0 Accident Homicide ❑Suicide ❑Undetermined ❑Pending U Circumstances Investigation IllCI Medical Certifier Name Title Connie Goedert Coroner Address 1400 St Route 9,Lake George Town,New York 12845 Death Certificate Filed District Number Register Number City,Town or Village Glens Falls 5601 395 Burial Date Cemetery,Crematory or Facility Name 09/11/2021 Pine View Crematory ❑Entombment Address X❑Cremation Queensbury,New York ▪Donation Z Removal Date Place Removed o Eland/or and/or Held F Hold Address RA 0 IL Date Point of CO ❑Transportation by Common Shipment Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596 Address 407 Bay Rd,Queensbury,New York 12804 Name of Funeral Firm Making Disposition or to Whom .- Remains are Shipped,If Other than Above 2 Address OC W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 09/10/2021 Registrar of Vital Statistics R96ertAndrew Curtis(E(ectronicalty Signed) (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 g-//2 Y/ Place of Disposition l 0e v.4.,1 t✓'r- 4. 2 (add s/ W Q (section) I r (lot number,) (grave number) 8 Name of Sexton or Person in Cha a of Premise y9OXd rel F-1)et,ad z (please print) W Signature S' Title 00-5 Ci,"C1" DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) Receipt Human remains of delivered on , 20 Pine View Cemetery Representing Ole funeral home named on burial permit Official Funeral Directors Reg.or License#