Marcinkevicius, Vitas NEW YORK STATE DEPARTMENT OF HEALTH �`
?3
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Vitas A. Marcinkevicius Male
Date of Death Age If Veteran of U.S.Armed Forces,
August 23,2006 57 War or Dates
Place of Death Town of Queensbury Hospital, Institution or 54 Sunset Trail
Z City,Town or Village Street Address
W Manner of Death X Natural Cause ElAccident ElHomicide ElSuicide ElUndetermined ElPending
CI Circumstances Investigation
✓ Medical Certifier Name Title
W Dr.Richard Leach,MD
Address
Glens Falls,NY 12801
Death Certificate Filed District Number Reter umber
City,Town or Village Queensbury,NY 5657
El Burial Date Cemetery or Crematory
8/24/2006 Pine View Crematorium
❑ Entombment Address
1 J Cremation Queensbury,NY
Date Place Removed
z ❑ Removal and/or Held
O and/or Address
Hold
Date Point of
G. ❑ Transportation Shipment
to by Common Destination
G Carrier
Date Cemetery Address
0 D• isinterment
Date Cemetery Address
❑ R• einterment
Permit Issued to Registration Number
Name of Funeral Home Regan&Denny Funeral Home 01519
Address
53 Quaker Road,Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
- Address
C
pW, Permission ist hereby granted to dispose of the human rem in described above as indicated.,
Date Issued b,mil () Registrar of Vital Statistics q ,Cl f r(-,..,_
(signature)
District Number 5657 Place Queensbury,NY .
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I—
Z Date of Disposition /d Sic)L Place of Disposition p,n.v: ✓ C f=i z,f„r 1„,•,
W (address)
2
W
CO (section)
(section) /� (lot number) (grave number)
0 Name of Sexton or Person in Charge of Premises h r• ) Se I nc Li
Z /� (please print)
W Signature C�j t tr Title Cf e nr.,'- r
DOH-1555 (02/2004) (over)