Lipins, Fricis NEW YORK STATE DEPARTMENT OF HEALTH St VI
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
:jr Fricis Liepins Male
Date of Death Age If Veteran of U.S. Armed Forces,
::,a,::' November 22, 2015 86 War or Dates i LA) _LL
, ..: Place of Death
i Hospital, Institution or
City, Town or Village Queensbury Street Address Westmount Health Facility
Manner of Death
1 (Natural Cause XI Accident I Homicide Suicide Undetermined L [Pending
Circumstances Investigation
Medical Certifier Name Title
r.. Roslyn Socolof MD
:.:; Address
4,r{d Gurney Lane Queensbury,NY
r...: Death Certificate Filed District Number Register Number
::•, City, Town or Village Queensbury ��I l'I
s
0 Burial Date Cemetery or Crematory
November 24, 2015 Pine View Crematorium
0 Entombment Address
0 Cremation Quaker Road, Queensbury,NY 12804
Date Place Removed
Z [ j Removal and/or Held
2 and/or Address
Ho
N Id
0 Date Point of
u) [ [Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
[ [Reinterment Date Cemetery Address
*rr Permit Issued to Registration Number
::: Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
qi:;: Address
r 407 Bay Road, Queensbury, NY 12804
:: Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
W.
Permission is hereby granted to dispose of the human remains described above as indicated.
:: Date Issued ll I ,y i c,0 I� Registrar of Vital Statistics + ` k__.
(signature)
;:.� District Number 5 Lp ) Place L_ V c c ,, • 10V/
identified above wer disposed
I--
I certify that the remains of the decedent of in accordance with this permit on:
d
uiDate of Disposition If/Z'((fc Place of Disposition /„ Ora G ioff,....
2 (address)
W
co
re (section) A (lot number) (grave number)
pName of Sexton or Person in Charge of Premises [heel Jtw4
Z (please print)
LU g Title itpt
Signature
(over)
DOH-1555(02/2004)