Tekmitchov, Apostol NEW YORK STATE DEPARTMENT OF HEALTH �2 H
Vital Records Section 4 Burial - Transit Permit
Name First Middle Last Sex
Apostol Tekmitchov Male
Date of Death Age If Veteran of U.S. Armed Forces,
November 23,2013 88 War or Dates
E,. Place of Death Hospital, Institution or
Z City, Town or Village Glens Falls Street Address Glens Falls Hospital
p Manner of Death Natural Cause El Accident El Homicide n Suicide ❑Undetermined 1-1 Pending
W Circumstances Investigation
w Medical Certifier Name Title
Daniel Way MD
Address
100 Park Street,Glens Falls,NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 So3
❑Burial Date Cemetery or Crematory
❑Entombment November 27,2013 Pine View Crematorium
Address
®Cremation 21 Quaker Road, Queensbury,NY 12804
Date Place Removed
ZZ ❑Removal and/or Held
and/or Address
Hold
N
O Date Point of
N ❑Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Renterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Road, Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped, If Other than Above
• Address
W
11. Permission is hereby granted to dispose of the human remains d
scribed ov indicated.
Date Issued if 27 f3 Registrar of Vital Statistics ail/
(signature)
District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition It-3-i5 Place of DispositionC��{dr�•-
2 (address)
co
(section) (lot number) (grave number)
pName of Sexton or Perso in Charge f Premises rt� lrlr 3flu)r11-1
Z (pease print)
Signature Title C17Ernt (L
(over)
DOH-1555(02/2004)