Shishik III, Sergay NEW YORK STATE DEPARTMENT OF HEALTH l
Vital Records Section la Burial - Transit Permit
Name First Middle Last Sex
Sergay Stephen Shishik Ill Male
Date of Death Age If Veteran of U.S.Armed Forces,
05/14/2016 43 War or Dates No
. Place of Death Hospital, Institution
Z City ,Town or Village City of Albany or Street Address Community Hospice at St. Peter's
0 Manner of Death Natural Undetermined Pending
W ® Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Circumstances U Investigation
W Medical Certifier Name Title
C) Thea Dalfino MD
Address
315 S. Manning Bvld. Albany, NY 12208
Death Certificate Filed District Number Register Number
City,Town or Village City of Albany 101 1043
Date Cemetery or Crematory
❑ Burial 05/17/2016 Pine View Cemetery
❑ Entombment Address
® Cremation Queensbury, NY
Date Place Removed
Z Removal and/or Held
Q ❑ and/or Address
-' Hold
CO
O Date Point of
CL Transportation Shipment
CO, El By Common Destination
p Carrier
❑ Date Cemetery Address
Disinterment
❑ Date Cemetery Address
Reinterment
Permit Issued To Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home 01078
Address
136 Main St. S. Glens Falls, NY 12803
•:.n Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
ce
W'
Q- Permission is hereby granted to dispose of the human remains desccibel above as indicated. �%�
Date 05/16/2016 /
Issued Registrar of Vital Statistics ��
(signature)
District Number 101 Place City of Albany, NY
I certify that the remains of the decedent identified above were disposed of in accordance
iwith this permit on:
Z Date of Disposition 6-1 i' f lL Place of Disposition n�,i/6✓ £ GmQ't ` -
W (address)
W
CO (section) lot number) (grave number)
0 (�
h
w: Name of Sexton or Person in Charge of Premises irl.S'tr -,/` Jt 0 �
(please print) r� AA
Signature a silfri Title C t,
(over)
DOH-1555 (02/2004)