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Ambrus, BelaNEWYORK STATE DEPARTMENT OF HEALTH L�� Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Male Bela Ambrus Date of Death Age If Veteran of U.S. Armed Forces, 09129/2019 1821ears War or Dates Place of Death Hospital, Institution or 37 Old Schroon Road, Chester Town Warren, New York 12860 City, Town or Village Chester Town Warren Street Address C) Manner of Death © Natural Cause Accident Homicide Suicide Undetermined Pending Circumstances Investigation U Medical Certifier Name Title G Dare Gaiotti-Grubbs MD Address 100 Park St, Glens Falls, New York 12801 Death Certificate Filed District Number Register Number City, Town or Village Chestertown 5652 14 Burial Date Cemetery, Crematory or Facility Name 09/30/2019 Cremation Entombment Address © Cremation Queensbury Hamlet, New York ElDonation a0 Removal Date Place Removed and/or Held F and/or Hold Address N RDate Point of to ❑ Transportation Shipment jj by Common Cdrrier Destination Disinterment Date Cemetery Address Rein termerrt Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Barton-Mcdermott Funeral Home Inc 00141 Address 9 Pine St, Chestertown, New York 12817 Name of Funeral Firm Making Disposition or to Whom (� Remains are Shipped, If Other than Above Address W CL Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 09/30/2019 Registrar of Vital Statistics Wiry Conway (ECectronicalfy Sigma) (signature/ District Number 5652 Place Chestertown, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: WDate of Disposition la h I 1 I Place of Disposition r . v'-' � 0(\' (address) W (section/ 'lwnumberJ ` (grave number) l/n/ '�• Jt Name of Sexton or Person in Charge of Premises ^r z /p se print) ul Signature Title D0H-1ri5F (07/18) D 1 of 2 PUBLIC HEALTH LAW § 4145• Deaths; burial and removal permits; disposition of remains. L No person in charge of any premises on which interments, cremations or other disposition of the body of a deceased person are made shall inter or permit the interment or other disposition of any body unless it is accompanied by a burial, cremation or transit permit, as provided in this article. 2. (a) The funeral director or undertaker shall deliver the burial permit to the person in charge of the place of burial or other disposition before interring or otherwise disposing of the body or shall attach the removal or transit permit to the box containing the body, when shipped by any transportation company, which permit shall accompany the remains to its destination, where, if within this state, it shall be delivered to the person in charge of the place of burial or other disposition. (b) Any person or other entity owning, operating, managing, or designated to receive the body of a deceased person at a place of burial, cremation, or other final disposition in this state, who receives the body of a deceased person, shall provide a receipt for the body to the funeral director, undertaker or registered resident who delivered such body. Each receipt shall (i) be endorsed by both such person and the funeral director, undertaker or registered resident, (ii) indicate the date the body was delivered, (iii) include the name of the funeral director, undertaker or registered resident delivering the body and the registration number of such funeral director, undertaker or registered resident, (iv) include the name of the registered funeral firm the funeral director, undertaker or registered resident represents, (v) include the name of the deceased person as it appears on the burial, cremation, or transit permit, and (vi) include the name of the owner, operator, manager, or person in charge of the place of burial, cremation, or other final disposition who received the body of the deceased person. A copy of such receipt shall be retained by the owner, operator, manager, or person in charge of the place of burial, cremation, or other final disposition for a period of not less than four years, and shall be made available for inspection by the division of cemeteries during normal business hours. The original copy of every such receipt shall be retained by the licensed funeral firm for a period of not less than four years pursuant to the rules and regulations of the department governing the maintenance of records. 3. The person in charge of the place of burial or other disposition shall endorse upon the permit, the date of interment, or cremation or other disposition over his signature, and shall return all permits so endorsed to the registrar of his district within seven days after the date of interment, cremation or other disposition. 4. When burying or otherwise disposing of the body of a deceased person in a cemetery or burial place having no person in charge, the funeral director or undertaker shall (a) sign the burial or removal permit, giving the date of burial; (b) write across the face of the permit the words "No person in charge; " and (c) file the burial or removal permit within three days with the registrar of the district in which the cemetery is located. 5. The person in charge of the place of burial, cremation, or other disposition shall keep a record of all bodies interred or otherwise disposed of on the premises under his charge, in each case stating the name of each deceased person, place of death, date of burial or disposal, and name and address of the funeral director or undertaker, which record shall at all time be open to official inspection. DOH-1555 (07/18) p 2 of 2 Public Health Law Sec. 4145(2b) 012569 Receipt Human remains of delivered on 20/ -Z-z x /I Pine View Cemetery 'Representing the funeral home named on burial permit Official Funeral Directors Reg. or License #