Cerrone, Virginia L .(1'....... " t to 70
NEW YORK STATE DEPARTMENT OF HEALTH / Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Virginia L Cerrone Female
Date of Death Age If Veteran of US.Armed Forces,
08/27/2022 80 Years War or Dates
IH Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
ILI• Manner of Death a Natural Cause Accident ❑Homicide Suicide DUndetermined ❑Pending
✓ Circumstances Investigation
W Medical Certifier Name Title
o Gamal Khalifa MD
Address
100 Park St,Glens Falls,New York 12801
DeaAth Certificate Filed sty Of Glens Falls District Number Register Number
City,Town or Village 5601 442
Burial Date Cemetery,Crematory or Facility Name08/29/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
Z❑Removal Date Place Removed
and/or and/or Held
I:: Hold Address
CO
0
a. Date Point of
U) Transportation
p by Common Shipment
Carrier Destination
❑Disinterment
Date Cemetery Address
Date Cemetery Address
El Reinterment
Permit Issued to Registration Number
Name of Funeral Home Edward L Kelly Funeral Home 00519
Address
PO Box 548,Schroon Lake,New York 12870
Name of Funeral Firm Making Disposition or to Whom
ll— Remains are Shipped,If Other than Above
2 Address
M
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 08/29/2022 Registrar of Vital Statistics !Megan_lain(2;Yettronua4SignrJJ
(signature/
District Number 5601 Place City Of Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
H ei,___
Z Date of Disposition St gold Place of Disposition
j11._
W (address)
W
NCC (section) (lot nlanberl111 t.i 3A(V4iit (grave number)
gName of Sexton or Person in Charge of Premi s
Z / �/,� (plea print/
IllSignature � Title 0014
DOH 1555(07/18)p1of2
a-
1 01 6 7 1
Public Health Law Sec. 4145(2b)
Receipt I
1 Human remains of delivered on , 20` {
e View Cemetery Representing the funeral home named on,byrial permit
Funeral Directors Reg. or License#' 1
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