Pavelich, George 92.1
NEW YORK STATE DEPARTMENT OF HEALTH Burial _ Transit Permit
Vital Records Section ----,
'= Name First Middle Last Sex
`°° George R. Paveliich Male
:;
.;, Date of Death Age If Veteran of U.S. Armed Forces,
,- December 25,2015 79 War or Dates
F. Place of Death Hospital, Institutiorflritage Commons Residential Health
.mil City, Town or Village Ticonderoga Street Address Care
ALI-
Manner of Death X Natural Cause Accident n Homicide Suicide Undetermined Pending
Circumstances Investigation
�? Medical Certifier Nam
Title
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Address
7l covPzit.oc q � 'zee 3
Death Certificate Filed r District Number Register Number ry;`o
City, Town or Village Ticonderoga 1564
❑Burial Date Cemetery or Crematory
December 29,2015 Pine View Crematory
❑Entombment Address
ii Cremation 21 Quaker Rd., Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
O - and/or Address
H Hold
N
p Date Point of
O. Transportation Shipment
a by Common Destination
Carrier
Disinterment
Date Cemetery Address
Reinterment
Date Cemetery Address
v Permit Issued to Registration Number
Name of Funeral Home Alexander-Baker Funeral Home 00037
Address
. 3809 Main Street,Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
,` Address
te
17
ti,,. Permission is hereby ranted to dispose of the human remai scribed ve ' dicated.
.n Date Issued Registrar of Vital Statistics
,- _------ (sign r )
District Number \sul Place , .C_ �si
I certify that the remains of the decedent identified above were disposed of in a rdance with this permit on:
z 6c
w Date of Disposition j2.2ry 6 Place of Disposition t�?i¢ 0 ek1
2 (addr s)
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tX (section) (lot number) (grave number)
QName of Sexton or Person in Charge of Premises a t. /i e.,rc Ge=m -e
Z (please print)
w Title - ,e`n e.'10
Signature
(over)
DOH-1555 (02/2004)