Natalie, John NEW YORK STATE DEPARTMENT OF HEALTH 1 - I -4 1 " I
Vital Records Section Burial - Transit Permit
Name First Middlg LLa t . Sex.
John •auliner Natalie Male
Date of Death Age If Veteran of U.S.Armed Forces,
03/27/2013 55 years War or Dates
}- Place of Death Hospital, Institution or
Z City, Xr (oKll��1Xe Saratoga Springs Street Address Saratoga Hospital
W Manner of Death Natural Cause 0 Accident 0 Homicide 0 Suicide Undetermined Pending
Circumstances Investigation
ill Medical Certifier Name Title
44 Mikhaild Mavashev M D
A e iurch Street, Saratoga Springs, N Y 12866
Death Certificate Filed District Number Register Number
City, 14AlrgoKttifilkie Saratoga Springs 4501 149
El Burial Date Cemetery or Crematory
04/01/2013 Pine View Crematory
[]Entombment Address —
;;;+]Cremation Queensbury N Y
Date Place Removed
El Removal and/or Held
..� and/or Address
E7 Hold
CA:
0 Date Point of
0$El Transportation Shipment
0 by Common Destination •
Carrier
Q Disinterment Date • Cemetery Address
Q Renterment Date Cemetery Address •
Permit Issued to Registration Number
:.•:: Name of Funeral Home Compassionate Funeral Care; Inc. 00364
'" Address
402 Maple Avenue, Saratoga Springs, N Y 12866
Name of Funeral Firm Making Disposition or to Whom .
• Remains are Shipped, If Other than Above
2 Address
Lu
f' Permission is hereby granted to dispose of the human remains described above as indica ed.
Date Issued 03/29/2013 Registrar of Vital Statistics cr.cvy.‘ !
(signature)
il District Number 4501 Place Saratoga Springs
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
• Date of Disposition t(-1'43 Place of Disposition �4uv arndoriv
(address)
in
ta
2 (section) k (lot number) S (grave number)
0.
Name of Sexton or Person in Charge f Premises i) i 11n.(�
lr i (please print)
• Signature "I -,-- Title f P N1R7 t)t2
(over)
DOH-1555 (02/2004)