Chionchio, Theresa Cirillo , /-----
3 0
NEW YORK STATE DEPARTMENT OF HEALTHL... /
Bureau of Vital Records Burial - Transit Permit
Name First Middle Last Sex
Theresa Cirillo Chionchio Female
Date of Death Age If Veteran of U.S.Armed Forces,
04/26/2022 95 Years War or Dates
H Place of Death Hospital,Institution or
Z City,Town or Village Malta Town Street Address 26 Rockrose Way,Malta Town,New York 12020
UJ
Manner of Death a Natural Cause Accident Homicide Suicide Undetermined Pending
V Circumstances Investigation
ILJ Medical Certifier Name Title
G Madison Zuis NP
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed Town Of Malta District Number Register Number
City,Town or Village 4560 28
Burial Date Cemetery,Crematory or Facility Name
"" 04/30/2022 Pine View Crematory
Entombment Address
li1Cremation Queensbury Town,New York
DDonation
ZO❑Removal Date Place Removed
and/or and/or Held
H Hold Address
N
0
O. Date Point of
CA❑Transportation
p by Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
EiReinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
1— Remains are Shipped,If Other than Above
2 Address
CC
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 04/29/2022 Registrar of Vital Statistics yennifer Marie.7fo(mes(ECectronicafySigned)
(signature)
District Number 4560 Place Town Of Malta
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
H 1
Z Date of Disposition 9 7o z_Place of Disposition A e </c -eµ. Cc-in 1-0 p-,(
W
2 (address)
W
N /sectio, /! number (grave number)
Q
0 Name of Sexton or Person in Charge o remise G�y�Qei`r D LJ0
Z / (please print)
1!J Signature — 4 Title Ce-P3A-
DOH-1555(07/i8)p 1 of 2
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Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#