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Sciancalepore, Cosmo Anthony �� ss NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit # ( Permit Bureau of Vital Records Name First Middle Last Sex Cosmo Anthony Sciancalepore Male Date of Death Age If Veteran of U.S.Armed Forces, 07/07/2023 71 Years War or Dates Place of Death Hospital,Institution or W City,Town or Village Glens Falls Street Address Glens Falls Hospital p Manner of Death Natural Cause EAccident Homicide Duicide FlUndetermined ❑Pending W Circumstances Investigation W Medical Certifier Name Title a Bo Li MD Address 100 100 Park St,Glens Falls,New York 12801 Death Certificate Filed City Of Glens Falls District Number Register Number City,Town or Village 5601 334 Burial Date Cemetery,Crematory or Facility Name 07/10/2023 Pine View Crematory Entombment Address ©Cremation Queensbury Town,New York DDonation ZO❑Removal Date Place Removed and/or and/or Held H Hold Address 0 a Date Point of U)❑Transportation Shipment by Common Carrier Destination ODisinterment Date Cemetery Address EI Reinterment Date Cemetery Address 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 l.— Remains are Shipped,If Other than Above 5 Address CC W 0- Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 07/10/2023 Registrar of Vital Statistics Megan Nolin(Electronically Signed) (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 1 110 23 Place of Disposition 2 (address) W CC (section) ILItotc_umber) (grave number) O Name of Sexton or Person in Charge o r mises ease print) 011 W Signature Title (r-& it me DOH-1555(07/18)p 1 of 2 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#