Rusu, Emil NEW YORK STATE DEPARTMENT OF HEALTH o w
Vital Records Section Burial - Transit Permit
t> Name First Middle Last Sex
}0 Emil Rusu Male
l;
fir;;; Date of Death Age If Veteran of U.S. Armed Forces,
E }:
"%%= July 22,2016 85 War or Dates n/a
�� Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address 162 Warren Street Apt 5
Manner of Death u_kiNatural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
Medical Certifier Name Title
'' Address
C IDS CIS
'F:j,s Death Certificate Filed ' District Number Register Number
City, Town or Village Glens Falls,NY 5601 3 j
❑Burial Date Cemetery or Crematory
❑Entombment July 26, 2016 Pine View Crematorium
Address
®Cremation 51 Quaker Road, Queensbury,NY 12804
Date Place Removed
ZZ ❑Removal and/or Held
and/or Address
E Hold
CO
O Date Point of
N ❑Transportation Shipment
'p by Common Destination
Carrier
❑Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
' Permit Issued to Registration Number
f Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
s. Address
`> 407 Bay Road,Queensbury, NY 12804
" Name of Funeral Firm Making Disposition or to Whom
1 Remains are Shipped, If Other than Above
Address
t�, Permission is hereby granted to dispose of the human remains described above as indicated.
'"" ; Date Issued -7 t 25//b Registrar of Vital Statistics 4, p' Lh*--)
?,, (signature)
TO
yr
- District Number 5 60, Place City of Glens Falls,NY 12801
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 7/Z4(/i, Place of Disposition giudk-4 (Ct .,.
2 (address)
W
N
CL (section) (lot number) r (grave number)
pName of Sexton or Person in Charge of Premises /istifil— ..) w
Z (Owe print)
W Signature 7J Title Crif iVi 1142
(over)
DOH-1555(02/2004)