Green III, George U.S. Department of State
Report of Death of an American Citizen Abroad
•
U.S. Embassy,Kyiv,Ukraine 05-19-2014
Post Date of Issue (mm-dd-yyyy)
SSA No. 053-82-0110
Name in full George Edward Green III Age 35
Date(mm-dd`yyyy)and Place of Birth 01-31-1979 Lake George, New York United States of America
Evidence of U.S. Citizenship US passport #447340798 issued on June 27,2009fD
Address in U.S.A. 198 Middle Rd,Lake George,NY 12845
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Permanent or Temporary Address Abroad 29 Petlyury St.,apt.46,Lviv,Ukraine
Date of death May 13 2014
Month Day Hour Minute Year
Place of death Emergency Hospital Lviv Ukraine _
Number and streeel or Hospitai/NoTEi -e -__ Country —-- --
Cause of death intracerebral hemorrhage according to the cause of death statement#486 issued by Lviv regional
Including authority for statement-if physician,include full name and official title,if any.
forensic bureau on 05/15/14 and death certificate#356777 issued by Lviv civil registrar's office on 05/15/14
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Disposition of the remains shipped for burial in the US
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Local law governing disinterment of remains provides that N/A
Disposition of the effects with Yulia Serdiuk,the spouse of the deceased
Person or official responsible for custody of effects and accounting therefore
Yulia Serdiuk,the spouse of the deceased
Traveling/residing abroad with relatives or friends as follows:
NAME ADDRESS
Yulia Serdiuk 26 Sykhivska St.,apt.66,Lviv Ukraine
Informed by telegram or telephone DATE(mm-dd yyvy)
NAME ADDRESS NOTIFIED
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Copy of this report sent to: DATE(nim-dd-yyyy)
NAME - _ ---- -- ----ADDRESS SENT
Yulia Serdiuk 26 Sykhivska St.,apt.66,Lviv Ukraine 05-22-2014
.lame Green 198 Middle Road Lake George NY 12845 05-22-2014
Notification or copy sent to Federal Agencies: SSA x_ VA CSC Other New York Department of Health
State Agency
The original copy of this document and information concerning the effects are being placed in the permanent files of the U.S.
Department of State,Washington,DC 20520.
Remarks: U.S.passport#447340798 is with Ukrainian authorities
(Continue on reverse" ?4
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[SEAL] Signature• . co -
Lioudmila Millman of the Unite. .f America.
— ---
Consul
DS-2060 (Former!),OF-I80) For Additional Certified Copies,see http://travei.state,gov/passport/fao/fact 5057.html
11-2012