Panos, James NEW YORK STATE DEPARTMENT OF HEALTH 17 sty
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
James Panos Male
Date of Death Age If Veteran of U.S. Armed Forces,
07/17/2015 83 War or Dates Yes
(unknown)
Place of Death
Hospital, Institution or
Z City, Town or Village T/O Chester Street Address 84 William Hill Road
Manner of Death 0 Natural Cause El Accident D Homicide D Suicide D Undetermined D Pending
UJCircumstances Investigation
"Ai Medical Certifier Name Title
Vincent Meyer, MD
Address
Ballston. Spa, NY
Death Certificate Filed District Number Register Number
City, Town or Village Chestertown 5652
"DBurial Date Cemetery or Crematory
07/20/2015 Pine View Crematory
DEntombment Address
®Cremation 21 Quaker Rd. , Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
2❑and/or Address
= Hold
fi)
O Date Point of
t�3
S❑Transportation Shipment
0 by Common Destination
Carrier
❑Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Alexander-Baker FH 00037
Address
3809 Main St . , Warrensburg, NY 12885
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
I
tki
Permission is hereby granted to dispose of the human ains ,escri ove s indjcated.
P �
Date Issued 07/20/2015Registrar of Vital Statistics / p_i
1/ (sig ature)
District Number 56J`' a Place je_60...",
I certify that the remains of the decedent identified ab ve were disposed of in accordance with this permit on:
Z
al Date of Disposition 71��1 is Place of Disposition f,�1)ti,, C --
(address)
Ili
0
CC (section) (lot number) (grave number)
a ci Name of Sexton or Person in Charge of Premises < �a-'1'f
(plikase print)
Ili
Signature Title tI
(over)
DOH-1555 (02/2004)