Yefimchyk, Yan I
S
TOWN OF QUEENB 21
PJ/-
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745.-4477
Funeral Director �� �C
Name � /
�' ' C Case#
Date Of Cremation pb
Time Cremation Started 2 �M
Time Cremation Completed
Type of Container Ca�c��
Remarks i
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12/04/2006 22:25 15184942948 BARTON MCDERMOTT FHN PAGE 02
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21 ouaw 42�.Queersebury, Wtw York. 12804
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Consailate Ot.neral of the Republic of
Belarus bi New York, USA
Y ETINICHYK L1 ANID LFA.NIUAVICH(P obi 3 9-49)
57 ZIielezaodurodinaya Street, Apr. 35
GzerzWuskiy area,Minsk rgion
Reptiblic of Belarpus
S3 rA TI:MEN 1
1, YEHIaLORYL,L.EANID LEANIDAV'ICH,consent that.my so:,,,, YEF'II'v CHYK JAIL
LEril+viIDikVICH,who died in�die IJnited. States of America, be cremated and buried in.the United
Statew of America
November 20,2006 I
al�nec3.
Certifying the true signataue,
the notary public doses not attest
to the facts expressed in this statement �
Nr vm. ber twouty second two thousand and six. City of Minsk, Republic of Eel anus.
1, Gotde%Alta Ivan^v,,u,nastwy public of the First Minsk City State Notary Office, certify
that this is a true signatuat of Yefwnchyk Lea id Leanidavieh, who resides in the kcpubdi4 of
Belarus,Minsk region, Dzeizhinsky area, city of Fanipol, 717 Zheleznodorozhnaya street,
apart:neut 35,who is l-Hawn,to me as a persor stated in this document, and who signed :and
sworn to tl�s staternez.it before me.
.Recorded in the register under N 32wq-430
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State fee collected 9.300 Rubles
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t -.u•a charges collected 1.870 Rubies j
Nota* Public.
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