Torok, Alexander a r
NEW YORK STATE DEPARTMENT OF HEALTH I' 63S'
Vital Records Section , . Burial - Transit Permit
Name First Middle Last Sex
Alexander Torok Male
Date of Death Age If Veteran of U.S. Armed Forces,
August 30, 2015 87 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Street Address Own Home
Manner of Death j Natural Cause ❑ Accident 0 Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
'', Medical Certifier Name Title
Thomas Coppens, Dr.
Address
3 Iron Gate Center Glens Falls 12801
Death Certificate Filed District Number Register Number
a . City, Town or Village 5 0 0 I L—i 29-
❑Burial Date Cemetery or Crematory
Pine View Crematory
,, El Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
and/or Address
Hold
Date Point of
to Transportation Shipment
by Common Destination
Carrier
❑ Disinterment Date Cemetery Address
❑ Reinterment Date Cemetery Address
ii* Permit Issued to Registration Number
5 Name of Funeral Home M.B. Kilmer Funeral Home-SGF 01078
Az Address
..; 136 Main Street, South Glens Falls NY 12803
`' Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
• Address
Permission is hereby granted to dispose of the human remains described above as i " ted.
Date Issued 7 3 i /15 Registrar of Vital Statistics (/'
(signatur)
District Number 560/ Place V CQMS -c,k `\ S , Al V
.wiip
: I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 9/31 13" Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) (lot number) (grave number)
' Name of Sexton or Person in Char a of Premises iT
(please print)
;? Signature Title6rt
(over)
DOH-1555 (02/2004)