Mehalick, James # 321
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
James Michael Mehalick male
* Date of Death Age If Veteran of U.S.Armed Forces,
n
5/3/2015 72 War or Dates Vietnam
H Place of Death Hospital, Institution or
W City, X YP��Xk G1 nsFalls Street Address 61ens Falls Hospital,
p Manner of Death 0 Natural Cause Accident Homicide Suicide Undetermined Pending
W Circumstances Investigation
W Medical Certifier Name Title
0 Aqeel A. Gillani M.D.
Address
102 Park St. Glens Falls N.Y. 12801
Death Certificate Filed District Number Register Number
City,fiziwcpxyilkotG1 ens Fall s 5601 23/
❑Burial Date Cemetery or Crematory
5/5/2U15 Pineview Crematory
❑Entombment Address
Cremation 21 Quaker Road Queensbur N.Y. 12801
Date Place Removed
Z Removal and/or Held
C❑and/or Address
C' Hold
fn
O Date Point of
N Q Transportation Shipment
O by Common Destination
Carrier
v.
Disinterment
Date Cemetery Address El
ReintermentIltr—i Date Cemetery Address
• Permit Issued to Registration Number
Name of Funeral Home Radloff Funeral Home Inc. 1425
1 Address
136 Warren Glens Falls N.Y. 12801
> Name of Funeral Firm Making Disposition or to Whom
I. Remains are Shipped, If Other than Above
2 Address
M
W
aPermission is hereby granted to dispose of the human remains , cri ed,�bodicated.
Date Issued (1p.5 /S Registrar of Vital Statistics ,I z::(
Ili / (signature)
114• District Number J(�,0/ Place 6/ `; ! AV
HI certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition Sf'JIS' Place of Disposition ,MVO Cr•—V--
2 (address)
W
to
cc (section) /got number) (grave number)
pName of Sexton or Person in Charge of Premises G k,4_ k' '
(please print "�
)
W Signature d� Title CU. ,..
(over)
DOH-1555 (02/2004)