Aliyev, Yuriy NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Yuriy Aliyev Male
Date of Death Age If Veteran of U.S. Armed Forces,
January 2,2014 76 War or Dates
Place of Death Hospital, Institution or
Z City, Town or Village Lake Placid Street Address 73 Seneca Trail
0 Manner of Death n Natural Cause I I Accident Homicide Suicide Undetermined Pending
W Circumstances Investigation
W Medical Certifier Name Title
O Woods McCahill,MD
Address
Placid Memorial Health Center,AMC-Lake Placid,Lake Placid,NY 12946
Death Certificate Filed District Number Register Number
City, Town or Village Village of Lake Placid 1523
❑Burial Date Cemetery or Crematory
January 3,2014 Pine View Crematory
Entanbnient Address
CI Cremation 21 Quaker Rd.,Queensbury,NY 12804
Date Place Removed
Z I +Removal and/or Held
and/or Address
H Hold
N
O Date Point of
N I I Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M.B. Clark,Inc. 01075
Address
2310 Saranac Ave.,Lake Placid,NY 12946
Name of Funeral Firm Making Disposition or to Whom
i— Remains are Shipped, If Other than Above
2 Address
DC
a
Permission is hereby granted to dispose of the human re s de ribe bovee//as indicated.
Date Issued 1-2-2014 Registrar of Vital Statistics �uya ( I!
(signature)
District Number 1523 Place Village of Lake Placid
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
wDate of Disposition I/1 IN Place of Disposition ?n.t
W (address)
U)
(section) f1 ( t qumber) (grave number)
Q Name of Sexton or Person in C rge of Premises ` r:r r st
h�
(phase print)
eftemitcy
Signature L Title
(over)
DOH-1555(02/2004)