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Puricelli, Robert Stanley 011 tt 21_3 NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Robert Stanley Puricelli Male Date of Death Age If Veteran of U.S.Armed Forces, 03/05/2024 78 Years War or Dates 1965-1968 H Place of Death Hospital,Institution or Z City,Town or Village Fort Edward Village Street Address 114 Gregory Lane, Fort Edward Village, New York 12828 0▪ Manner of Death ❑� Natural Cause nAccident ❑Homicide Suicide nUndetermined ❑Pending W U Circumstances Investigation uJ Medical Certifier Name Title CI Howard Silverberg MD Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed Town Of Fort Edward District Number Register Number City,Town or Village 5755 Burial Date Cemetery,Crematory or Facility Name 03/07/2024 Pine View Crematory IllEntombment Address ©Cremation Queensbury Town,New York Donation 0❑Removal Date Place Removed and/or and/or Held 1 Hold Address CO 0 a. Date Point of CO❑Transportation Shipment Q by Common Carrier Destination ri Disinterment Date Cemetery Address ❑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 — Remains are Shipped,If Other than Above ,N Address CC W a. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 03/07/2024 Registrar of Vital Statistics Aimee L Mahoney(Electronically Signed) (signature) District Number 5755 Place Town Of Fort Edward I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: I- WDate of Disposition Z--9-,2Q2y Place of Disposition �`1ve Iv`e.J L'��'4 r� 2 (address) W Q (section) (lot number) (grave number) SName of Sexton or Person in Chargejeise A-kW/A ,,� ariet z , (please print) W Signature Title o0� DOH-1555(018)p 1 of 2 Public Health Law Sec. 4145(2b) IReceipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit OfficialFuneral Directors Reg.or License#