Sclafani, Mary Eileen 4.
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NEW YORK STATE DEPARTMENT OF HEALTH [CF.).Bureau of Vital Records Burial - Transit Permit
Name First Middle Last Sex
Mary Eileen Sclafani Female
Date of Death Age If Veteran of U.S.Armed Forces,
05/13/2022 78 Years War or Dates
p— Place of Death Hospital,Institution or
Z City,Town or Village Kingsbury Town Street Address 3 Melony Lane,Kingsbury Town,New York 12839
p▪ Manner of Death ❑X Natural Cause Accident D Homicide Suicide Undetermined ElPending
Circumstances Investigation
W Medical Certifier Name Title
CI Sean Campanie NP
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed Town Of Kingsbury District Number Register Number
City,Town or Village 5762 10
Burial Date Cemetery,Crematory or Facility Name
05/16/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
Q❑
Removal Date Place Removed
and/or and/or Held
~ Hold Address
N
0
O. Date Point of
U)❑Transportation
p by Common Shipment
Carrier Destination
Ei
Disinterment
Date Cemetery Address
❑Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M B Kilmer Funeral Home-Fort Edward 01079
Address
82 Broadway,Fort Edward,New York 12828
Name of Funeral Firm Making Disposition or to Whom
1.— Remains are Shipped,If Other than Above
S Address
CC
W
n' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 05/16/2022 Registrar of Vital Statistics Cynthia Bard-in(ECectronicaCCy Signed)
(signature)
District Number 5762 Place Town Of Kingsbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition 3-IId17-L Place of Disposition ai._ Ll�`
Ili
2 (address)
W
CD
CC (section) (lot number) µ (grave number)
0 Name of Sexton or Person in Charge f Premises di`i (` 1/4—SA `1
Z (plea print)
IL Signature Title
l ✓M��r
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
1
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#