Zverbus, Frank NEW YGIAK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last ZVer Sex
Frank Joseph Z Ba Male
Date of Death Age If Veteran of U.S. Armed Forces,
04/o7/2n13 93 years War or Dates WW II
Place of Death Hospital, Institution or
utZ City, To"WAVKA AAA Glens Falls Street Address GIPns Fails Hospital
Manner of Death❑�latural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
IILI Circumstances Investigation
iti Medical Certifier Name Title
Q Mathew Varughese MJn
Address
iiii
100 Park Street Glens Falls, Ny 12801
iiiii Death Certificate Filed District Number Register Number
City, TowTolick2kVill#SeirY C;IPns Fails 5An1 149
Mi❑purial Date Cemetery or Crematory
❑Entombment Address04/13/2013 Pine View Cemetery
❑Cremation Queensbury, NY 12804
Date Place Removed
gEl❑Removal and/or Held
00. and/or Address
M"" Hold
U)
Date Point of
11 0 Tr0. ansportation Shipment
C by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
gi Name of Funeral Home Maynard D. Baker Funeral Home 01130
Address
11 Lafayette Street Queensbury, N Y 12804
>< Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
LU
fl' Permission is hereby granted to dispose of the human remains described above as indicated.
illi!6 Date Issued 04/08/2013 Registrar of Vital Statistics �t\7Cjvv � LA)s-A-N,cer
(signatur
District Number Place y 5601 Glans Falls 1
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k
la Date of Disposition 4/1 3/1 3 Place of Disposition Pine View Cemetery
2 (address)
0 Hudson Sec. 1 16 K 1
CC (section) (lot number) (grave number)
Name of Seiton or Person in Charge of Premises Connie Goedert
(please print)
10
Signatur ` ' .� ��•( -)- Title Superintendent
(over)
DOH-1555 (02/2004)