Paliulis, Vytautas 3 it NEW YORK STATE DEPARTMENT OF HEALTH I'
Vital Records Section Burial - Transit Permit
. Y
Name First Middle Last I Sex
Vytautas Petras Paliulis Male
Date of Death Age If Veteran of U.S. Armed Forces,
October 6, 2015 72 War or Dates
I- Place of Death Hospital, Institution or
W. City, Town or Village Northumberland Street Address 674 West River Road
W' Manner of Death Natural Cause ❑ Accident ❑Homicide ❑ Suicide ❑ Undetermined El❑ Pending
Circumstances Investigation
W Medical Certifier Name Title
CI William Papura, D.O.
; Address
= 11 34 State Rte 29 Greenwich, NY 12834
Death Certificate Filed I J District Number Register Number
City, Town or Village fU M 111,1141 -P f'((l V)ll 1-1"�1.03 I i
❑Burial Date Cemetery or Crematory
October 13, 2015 Pine View Crematorium
_❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
"'`° Date Place Removed
z ❑ Removal and/or Held
• and/or Address
L Hold
CO Date Point of
e;❑Transportation Shipment
CO, by Common Destination
I Carrier
❑ Disinterment Date Cemetery Address
❑ Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped, If Other than Above
• Address
ce
W:
a. Permission is hereby ranted to dispose of the human remains describe aabbo,�vf as indicated.
Date Issued /0 Registrar of Vital Statistics ��� ' Le,
(signature)
District Number 1-1-5-/p3 Place Nor44
uv1 cev lu yld_
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
IF
W. Date of Disposition 10/13/2015 Place of Disposition Quaker Road Queensbury,NY 12804
2 (address)
W;
LE (section) /i (lot number)c (grave number)
in• Name of Sexton or Person in Charge of Premises G rJ; Jt•n ti
As f ( lease print)
W' Signature ( � Ls Title « a-
(over)
DOH-1555 (02/2004)