Sarvakis, Stephen NEW YORK STATE DEPARTMENT OF HEALTH ' '' Burial - raZ1 Permit
Vital Records Section
Name First Middle Last Sex
Stephen Sarvakis Male
Date of Death Age If Veteran of U.S.Armed Forces,
F April 8, 2016 81 War or Dates
z Place of Death Hospital, Institution or
W City,Town,or Village Granville Street Address The Orchard Nursing Centre, Inc.
0 Manner of Death X❑Natural Cause El Accident 0 Homicide ri Suicide ❑Undetermined 0 Pending
W Circumstances Investigation
a Medical Certifier Name Title
W Dr. Jennifer Hayes, M.D. Dr.
0 Address
17 Madison Street, Granville, NY 12832
Death Certificate Filed District Number Register Number
City,Town or Village Granville 5 95 1�0 I
❑Burial Date Cemetery or Crematory
April 12, 2016 Pineview Crematorium
❑Entombment Address
0 Cremation 21 Quaker Road Queensbury, NY 12804
Date Place Removed
0 0 Removal and/or Held
and/or Address
Im Hold
0 Date Point of
0 0 Transportation Shipment
Di by Common Destination
Carrier
Date Cemetery Address
a0 Disinterment
Renterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Jillson Funeral Home, Inc. 00885
Address
46 Williams Street, Whitehall, New York 12887
I- Name of Funeral Firm Making Disposition or to Whom
ii Remains are Shipped, If Other than Above
W Address
0.
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued y/(a 12-0(Le Registrar of Vital Statistics c,� 94,
(signature)
District Number 513Lp Place Granville,New ork
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
wDate of Disposition 04/12/2016 Place of Disposition Pineview Crematorium
2 (address)
ttl
00 (section) C�(lot number) . (grave number)
Name of Sexton or Person in Charge of Premises h�cye._ Sv,,.*
tuase print)
Signature Title a(zif 4-
(over)
DOH-1555 (02/2004)