Sousis, Shawn tZ(43
NEW YORK STATE DEPARTMENT OF HEALTH,-
Vital Records Section Burial - Transit Permit
iiiiiiii Name First Middle Last Sex
Shawn Joseph Sousis Male
iii,x, Date of Death Age If Veteran of U.S. Armed Forces,
05/16/2012 48 years War or Dates No
. i4 Place of Death Hospital, Institution or
City, ToICRAKVARIa Schenectady Street Address Ellis Hospital
1 Manner of Death UIatural Cause ❑Accident 0 Homicide 0 Suicide D Undetermined 0 Pending
Circumstances Investigation
119 Medical Certifier Name Title
Natalya Rukavishnikova - M D
giii Address
1101 Nott St, Schenectady, N Y 12308
Oi Death Certificate Filed District Number Register Number
igii City, TovXXXO Vj.X%XX Schenectady 4601 467
Date Cemetery or Crematory
❑Burial 05/17/2012 Pine View Crematory
Address
rfrremation Queensbury, N Y
Date Place Removed
4❑Removal , and/or Held
•.• and/or Address
gHold
Q Date Point of
NQ Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
'<` Permit Issued to Registration Number
ii Name of Funeral Home M B Clark Funeral Home 01112
li Address
iiA 196 Elm St, Champlain, N Y
iiiiiiiii Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
M
Permission is hereby granted to dispose of the human remai Iclesgiibed oye i,ndic�t d.
(( hh ? ;
€<s Date Issued 05/17/2012 Registrar of Vital Statistics _,��-i����'�-'t ;�=�'����i �"u�
(signature) U
District Number 4601 Place Schenectady
I certify-that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition Sit fit Place of Disposition -R40to C, ani.••
2 (address)
Lq
tC (section) e (plot number) (grave number)
GName of Sexton or Person in Char e of Premisesrokyp�4,.d
(please print) IUD
W Signature 8Title ( ni apt
(over)
DOH-1555 (9/98)