Sousis Sr, Justin iiiNEW Y tRK STATE DEPARTMENT OF HEALTH '` � "
Vital Records oettonBurial - Tra n 1 rm it
Name First JUSTIN Middle MICHAEL Last SOUSIS, SR. Sex M
%/� Date of Death 5/30/2014 Age 32 If Veteran of U.S. Armed Forces,
War or Dates N/A
Place of Death Hospital,Institution or
City, Town or Village CITY ELMIRA Street Address AOMC
/ Manner of Death ® Natural Cause [' Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
Medical Certifier Name DOUGLAS MCKANE Title MD
Address 812 W 2ND ST ELMIRA NY 14905
Death Certificate Filed City of Elmira District Number 700 Register Number 420
City,Town or Village
'�///' ❑ Burial Date 6/6/2014 Cemetery or Crematory PINE VIEW CREMATORY
❑ Entombment Address QUEENSBURY,NY
// ® Cremation
/ ❑ Removal
Date Place Removed
/ and/or and/or Held
Hold Address
Date Point of
❑ Transportation Shipment
by Common Destination
Carrier
I ❑ Disinterment Date Cemetery Address
❑ Reinterment Date Cemetery Address
Permit Issued to WILCOX®AN FUNERAL HOME Registration Number 01821
�, Name of Funeral Home
�'.'j Address 11 ALGONKIN ST. TICONDEROGA,NY 12883
'/�// Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains sc i above as indi ated.
"//,�: Date Issued 6/2/2014 Registrar of Vital Statisti s3r
' .. (signature)
District Number 700 Place Chemung County Vital Records-P.O.Box 588 Elmira,NY
', I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
• Date of Disposition G-il-i'4 Place of Disposition 'PA., Lr+. "or,w--
(address)
f /
II (section) (lot numbe(r'4 (grave number)
/ Name of Sexton or Person in Charge of Premises dinik. �eMe
(please print)
Signature f; /�' Title 00141174.
(over)
DOH- 1555