Shenko, Roy NEW YORK STATE DEPARTMENT OF HEALTH --* ‘ *' 2/C
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Roy Shenko Male
Date of oDeath Age If Veteran of U.S. Armed Forces,
March 20, 2016 61 War or Dates
t. Place of Death City of GLens Falls Hospital, Institution or Glens Falls Hospital
City, Town or Village Street Address
ILIa Manner of Death m Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
til Medical Certifier Name Title
11 Stepeen Pevazzelli MD
Address
100 Park St. Glens Falls, New York 12801
Death Certificate Filed City of Glens FaL strict Number Register Number
City, Town or Village 5601 7 7
ip 0 Burial Date Cemetery or Crematory
March 21 , 2016 Pine View Crematory
i ;i ❑Entombment Address
;;;;::Cremation 21 Quaker Road Queensbury, New York 12804
Date Place Removed
Z❑Removal and/or Held
9 and/or Address
H Hold
'Ii
Date Point of
Transportation Shipment
C1 by Common Destination
Carrier
m LiDisinterment Date Cemetery Address
Renterment Date Cemetery Address
m: LiPermit Issued to M. B. Kilmer Funeral Home Registration Number
Name of Funeral Home 01078
Address 136 Main St. South Glens Falls, New York 12803
Name of Funeral Firm Making Disposition or to Whom
i4 Remains are Shipped, If Other than Above
Address
cr
11
Permission is hereby granted to dispose of the huma remains escribed above as i icate .
Id Date Issued 3/21 /2016 Registrar of Vital Statistics
(sign ture)
District Number 5601 Place City of Gle s Falls, New York
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILI Date of Disposition 3/2y116 Place of Disposition -6.00-1 Cowirflon,
2 (address)
Ui
tft
IX (section) Plot number (grave number)
Name of Sexton or Person in Charge f Premises distil., 8,,,„d
zlease print)
Signature Titleeuittaii
(over)
DOH-1555 (02/2004)