Motisi, Sebastian NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Sebastian Benny Motisi Male
Date of Death Age If Veteran of U.S. Armed Forces,
August 13,2013 89 War or Dates
F- Place of Death Hospital, Institution or
Z City, Town or Village Glens Falls Street Address The Pines Of Glens Falls
pManner of Death Natural Cause Accident �Homicide Suicide Undetermined Pending
to Circumstances Investigation
W Medical Certifier Name Title
O Maureen Hyland,FNP
Address
170 Warren Street,Glens Falls,NY
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls,NY 5601 3L'9
®Burial Date Cemetery or Crematory
❑Entombment August 16,2013 Pine View Cemetery
Address
❑Cremation Quaker Road,Queensbury,,NY 12804
Date Place Removed
ZZ Removal and/or Held
and/or Address
H Hold
N
O Date Point of
D Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Renterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Road,Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
F- Remains are Shipped, If Other than Above
2 Address
iY
tJJ
• Permission is hereby granted to dispose of the human remains described above a's indicated.
Date Issued g'1``/f 13 Registrar of Vital Statistics WC ,Z W
(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:
w Date of Disposition 8/1 6/1 3 Place of Disposition Pine View Cemetery
Lu (address)
Huron 1H 1
(section) (lot number) (grave number)
0 Name of Se or Person in Charge of Premises Connie L. Goedert
(please pant)
Signature `� cLt Title Superintendent
(over)
DOH-1555(02/2004)