Belenki, Emmanuil A IA 2_
NEW YORK STATE DEPARTMENT OF HEALTH o l Vital Records Section Burial - Transit Permit
r;.; Name First Middle Last Sex
...'. Emmanuil Belenki Male
Y'; Date of Death Age If Veteran of U.S. Armed Forces,
', October 29, 2014 90 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Queensbury Street Address Stanton Nursing & Rehab Centre
Manner of Death — Undetermined Pending
XI Natural Cause Accident I 1 Homicide Suicide Circumstances Investigation
Medical Certifier Name Title
Bernardo R.Villajuan Dr.
`�r Address
r; 88 Broad St, Glens Falls,NY 12804
ii. Death Certificate Filed District Number Register Number
ki City, Town or Village Town of Queensbury 5657 t 43
0 Burial Date Cemetery or Crematory
October 30, 2014 Pine View Crematorium
❑Entombment Address
Ox Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
F_- Hold
N`
p Date Point of
NTransportation Shipment
p by Common Destination
Carrier
n Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
r` Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
:' Address
•1 53 Quaker Road, Queensbury,NY 12804
{ 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 r 'n de. -d •boy- asp.icated.
.!..
Date Issued 10 —�bi4-Registrar of Vital Statistics ,(,�,� 4, .. Nr.
sign. e
: ; District Number 5657 Place Town of Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition AAA Place of Disposition eg. (I . Crt 0r4,.•...
W' (address)
N
0 (section) dir,s
(lot number) (grave number)
p` Name of Sexton or Person 'n Charge of Premises ��ordir
Z ( 1:aase print)
W
Signature `l Title Ct26;14492....
(over)
DOH-1555(02/2004)