Simione, Michael Anthony Ici) lit 1(f)
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Michael Anthony Simione Male
Date of Death Age If Veteran of U.S.Armed Forces,
12/15/2022 88 Years War or Dates 1952-1954
1,,., Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
p Manner of Death El Natural Cause []Accident El Homicide ESuicide nUndetermined []Pending
W
C.) Circumstances ' !!Investigation
W Medical Certifier Name Title
CI Gamal Khalifa MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed City Of Glens Falls District Number Register Number
City,Town or Village 5601 631
R
Burial Date Cemetery,Crematory or Facility Name
12/19/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
Z❑Removal Date Place Removed
and/or and/or Held
F- Hold Address
N
0
a Date Point of
U)❑Transportation Shipment
Q by Common
Carrier Destination
II
Date Cemetery Address
Disinterment
❑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
N Address
CC
111
Cl-
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/19/2022 Registrar of Vital Statistics MeganNoCrn(Electronica/T Signer))
(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:
WDate of Disposition Wig I'LZ Place of Disposition �".�� 6,_
2 (address)
W
(I))CC syvvi
(section) /Jf (loxnumber) (grave number)
0 Name of Sexton or Person in Ch2em
ge Pises llvvC '(1"vL" tt
z (ple e print)
W CV
Signature i-• Title �RF �f
DOH-1555(07/18)p 1 of 2
i.
1 � t'
Public Health Law Sec. 4145(2b)
Receipt
Human remains of r delivered on - , 20
Pine View Cemetery Representing the funeral home named on l;urial,,permit
Official Funeral Directors Reg.or License#