Virag, Louis NEW Yt*RK SATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last I Sex
Louis Viral Male
Date of Death Age If Veteran of U.S. Armed Forces,
January 24,2014 57 War or Dates _
Place of Death Hospital, Institution or
1Z City, Town or Village Malta Street Address 2865 Route 9,Apt#103
GManner of Death 'X Natural Cause + 1 Accident I I Homicide Suicide Undetermined Pending
W Circumstances Investigation
W Medical Certifier Name Title
O Michael Sikirica MD
— _ —
Address —— — ---
_ 50 Broad Street,Waterford,NY 121.88_
Death Certificate Filed District Number Register Number
City, Town or Village
0 Burial Date Cemetery or Crematory
Entombment February 20,2014 Pineview Cemetery _
Address
❑Cremation_ _ Town of Queensbury, NY
Date 1 Place Removed
Z Removal
! and/or Held
and/or
Address
H Hold
Cl)
00 Date Point of
( 1 Transportation _ Shipment
p by Common Destination
Carrier
1 Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
LPermit Issued to Registration Number
Name of Funeral Home Mevec Funeral Home Inc. 01176
Address
224 Milton Avenue, Ballston Spa, NY 12020
Name of Funeral Firm Making Disposition or to Whom
i Remains are Shipped, If Other than Above
"S Address
Ce
IL
Permission is hereb granted to dispose of the human remains described above as indicated.
Date Issued 009�H Registrar of Vital Statistics — r .p(0, 'zO\
(signature)
District Number 4520 Place Village of Ballston Spa
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
H
Z 2/20/201 Pine View Cemetery
w Date of Disposition lace of Disposition
2 (address)
w
co Horicon 6 E 1
(section) (lot number) (grave number)
Q Name of Sexto or Person in Charge of Premises Connie L. Goedert
Z (please print)
w Su erintendent
Signature Title P
(over)
DOH-1555 (02/2004)