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Gagliano, Samuel NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle _ Last Sex Samuel Gagliano Male Date of Death Age If Veteran of U.S.Armed Forces, 08/29/2023 73 Years War or Dates Place of Death Hospital,Institution or Z City,Town or Village Ulster Town Street Address Northeast Center For Special Care ILI p Manner of Death E Natural Cause Accident ❑Homicide Suicide Undetermined Pending W Circumstances Investigation W Medical Certifier Name Title CI Richard Stutt MD Address 239 Golden Hills Lane,Kingston,New York 12401 Death Certificate Filed Town Of Ulster District Number Register Number City,Town or Village 5567 121 A.Burial Date Cemetery,Crematory or Facility Name 09/12/2023 Pine View Cemetery Entombment — Address Cremation Queensbury,New York Donation 0❑Removal Date Place Removed and/or and/or Held NHold Address 0 Q. Date Point of (I)EITransportation Shipment Q by Common Carrier Destination Date Cemetery Address Disinterment CI Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Regan Denny Stafford Funeral Home 01443 Address 53 Quaker Rd,Queensbury,New York 12804 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped,If Other than Above X Address MC Ill EL Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 09/05/2023 Registrar of Vital Statistics Suzanne Louise wavy(ELectronica1ty Signed) . (signature) District Number 5567 Place Town Of Ulster I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:WNuDate of Disposition .( Place of Disposition Q} � uo O e�l1 S� I^/y /c)e ' 0 2 (address) ( r ) W Cfi IX ion) t (lot number)mb (grave number) 8 Name of Sexton or Person in Charge of Premises �Q11'ni. z .t (please print) ` W Signature 444:4 od Title ui t� AcsAC4E,rlT DOH-1555(07/18)p 1 of 2 Public Health Law Sec.4145(2b) li 129 9 5 • Receipt 9- / — 1- Human remains of 36-,-", tA 4?- / (-7,A ,, 4 '''-`4 9 delivered on , 20 1 7/ 'ne View Cemetery Representing the funeral home named on burial permit Official i Funeral Directors Reg.or License# GAGLIANO LF Lot No. 62 Address 1147 Webster Drive, Wilmington, DEL 19803 Section No. Owner Mr . Louis J. Gagliano Plot Mohican Date 9/19/91 Approx. 200 Superficial ft. @ Location Bounded on North by Path, South by Vacant , East by Vacant . West by Path. Corner Posts Remarks !�v (/ Z. 6 L; i S� � ct C4/� u n/G+ �- mot""' T-C. © c�i 3 7 7 i 6 c Ui c �� jQ.. r QYQr?n �: c-�j,, � . 4z- u/ 3 ;.? Deed No. (and changes) 2375 Payment Record Paid in Full 9/19/91 Record of Interments —27'Sa i-NX Cam"\;oW13 Q-I'D- k4.8 V 2 VS /4 3A . I nuin .1 Angglian° 1A/9/99 4 Mary Elizabeth Gagliano ( 9/15/12) „ , a = f s 7 8 �' 4 C � -r L ) e\ Form No. 01 -- ,j 1 \ GAGLIANO NAME Samuel �Gagliano \ ) Age: 73 g ' Lot Owner:Loui s J Gagliano Lot# Mohican 62 Grave# 2 Case: Concrete Died: 8.2 9.2 3 Interred: 9. 1 2.2 3 Funeral Home: Regan Denny Stafford Cemetery: Pine View