Derusha Jr. Lewie NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last 1 Sex
Lewie Henry Derusha Jr. , Male
Date of Death ' Age ' If Veteran of U.S. Armed Forces,
7/1 2/1 1 60 War or Dates Vietnam
▪ Place of Death Hospital, Institution or
• City, Town or Village Argyle Street Address PVI 4573 St. Rt. 40, Argyle
. Manner of Death®Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
UI Circumstances Investigation
2 Medical Certifier Name Title
p Edit Yasaha MD
gi Address
il 1134 St. Rt. 29, Gree-iwich, NY 12814
ini Death Certificate Filed District Number Register Number
ilii City, Town or Village Argy1P .59 5Z3 <7
Date Cemetery or Crematory
❑Burial 7/1 5/1 1 Pine View Crematory
Address
❑Cremation Quaker Road, queensbury, NY
Date Place Removed
0 ❑Removal and/or Held
and/or Address
Hold
E
Q Date I Point of
515 ❑Transportation I Shipment
a by Common Destination
HE Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
0 Permit Issued to Registration Number
iiip Name of Funeral Home M.B. Kilmer Funeral Home 01 077
Address
"? 123 Main St. Argyle, NY 12809
i. Name of Funeral Firm Making Disposition or to Whom
" Remains are Shipped, If Other than Above
Address
A
ni Permission is hereby granted to dispose of the humanains described above as indicated.
niii Date Issued -)i)`--i / ( ( _ Registrar of Vital Statistics , . a
nature) k
iiiU
i Place QcQ�I) G ' --
; District Number )5-0
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition III Ili Place of Disposition IN.004%) frVac,f Of
(address)
W
U)
CC (section) / _ ( t number) (grave number)
O Name of Sexton or P rson in Char a of Premises G its{ r- -gyp h,et
(please print)
W Signature L �� Title rf f in* tJ) -
DOH-1555 (10/89) p. 1 of 2 VS-61