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Amiano, David NEW YORK STATE DEPARTMENT OF HEALTH 1110F Burial - Transit Permit Bureau of Vital Records - Name First Middle Last Sex David Amiano Male Date of Death Age If Veteran of U.S.Armed Forces, 11/20/2023 58 Years War or Dates p, Place of Death Hospital,Institution or WCity,Town or Village Lake George Village Street Address 75 Dieskau Street 6,Lake George Village,New York 12845 W Manner of Death ©Natural Cause ❑Accident Homicide EI Suicide Undetermined Pending Circumstances Investigation MIMedical Certifier Name Title Lynn Keil PA Address 9 Carey Road,Queensbury Town,New York 12804 Death Certificate Filed Village Of Lake George District Number Register Number x City,Town or Village 5620 7 't Burial Date Cemetery,Crematory or Facility Name ,,,, 12/01/2023 Pine View Cemetery Entombment Address „f ❑Cremation Queensbury Town,New York • Donation AEIRemoval Date Place Removed and/or and/or Held LI Hold Address Transportation Date Point of by Common Shipment It.l Carrier Destination ,1 ElDisinterment Date Cemetery Address ■ Reinterment Date Cemetery Address , Permit Issued to Registration Number _' Name of Funeral Home Regan Denny Stafford Funeral Home 01443 Address 40. 53 Quaker Rd,Queensbury,New York 12804 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped,If Other than Above Address Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 11/28/2023 Registrar of Vital Statistics Julie A en(ElectronicafySigned) /signature/ District Number 5620 Place Village Of Lake George I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: / V, j Z `1 � Date of Disposition �a•���� Place of Disposition cal� (�`},Q new�� �.a,����ji ��r j1/l,J 2 (address) 1 W VAOR i C.CY1 50 6 1 cc wn/ // umber/ (grave number) gName of Sexton or Person in Charge of Premis Ca,n► ( L5?A z /�� (please print) W Signature s Title ---)live>c- t r, DOH-1555(07/18)p 1 of 2 d Public Health Law Sec. 4145(2b) Receipt Human remains of delivered on `/. • !J , 20 `> • P,ibe View Cemetery Representing the funeral home named on burial permit official Funeral Directors Reg.or License# SCHELLER/AMIANO Owner ( F) Jenna Scheller Address Plot 825 Gerling St. Schenectady, NY 12308 Horicon Phone # Lot # 518-368-3384 30G Deed # Date 4420 17_1 _23 Cost Foundation Y - N &800.00 Location West-Fries North-Vacant South-Canale East-Rozakis Remarks I ACKNOWLEDGE THE RECEIPT OF THE RULES AND REGULATIONS OF THE PINE VIEW CEMETERY: SIGNATURE: DATE: SIGNATURE: DATE: Record of Interments �. I I• ao-a3 1 �� ��►c� �a ' t a 6 2 7 3 8 4 9 5 10 • a J v-) a C e o- ,3 AMIANO NAME David Amiano Age: 58 Lot Owner: Jenna Scheller Lot# Horicon 30G Grave# 1 Case: Concrete Died: 1 1 .2 0,23 Interred: 1 2 . 1 .23 Funeral Home: Regan Denny Stafford Cemetery: Pine View