Caiazzo, Daureen J 0
NEW YORK STATE DEPARTMENT OF HEALTH # 3Sa
Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Daureen J.Caiazzo Female
Date of Death Age If Veteran of U.S.Armed Forces,
04/17/2023 83 Years War or Dates
F— Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
W
p Manner of Death 1-1 Natural Cause Accident t i Homicide []Suicide []Undetermined []Pending
U l 'Circumstances l 'Investigation
0 Medical Certifier Name Title
Abigail Macomber PA
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 196
[ ]Burial Date Cemetery,Crematory or Facility Name
04/18/2023 Pine View Crematory
[ ]Entombment Address
[]Cremation Queensbury Town,New York
Donation
Z❑Removal Date Place Removed
and/or _ and/or Held
I Hold Address
N
0
a- Date Point of
(R[]Transportation
p by Common Shipment
Carrier Destination
Date Cemetery Address
[]Disinterment
Date Cemetery Address
[]Reinterment
Permit Issued to Registration Number
Name of Funeral Home M B Kilmer Funeral Home-South Glens Falls 01078
Address — — --136 Main St,S Glens Falls,New York 12803
Name of Funeral Firm Making Disposition or to Whom
F. Remains are Shipped,If Other than Above
Address
Q
ILI -- —
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 04/17/2023 Registrar of Vital Statistics :V z,,it/oi,,(Elctram/az 11,5' aerl)
(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 �
Z Date of Disposition L 2 z, 3 Place of Disposition r r cJ e ✓ew (— 1 h p,l
ILI
2 (address)
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(n — - —
CC (section) (l t nu ber) (grave number)
0 Name of Sexton or Person in Charge Premises K 4 Of f)
Z / please print)
Ill Signature � Ldl� Title `i��t-ti-�m
c'" 'DOH-1555(07/18)p 1 of 2
V -,
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#