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Farbaniec, Philip John
.. -... . 9(t 9 NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Philip John Farbaniec Male Date of Death Age If Veteran of U.S.Armed Forces, 11/11/2021 86 Years War or Dates ▪ Place of Death Hospital,Institution or W• City,Town or Village Queensbury Town Street Add ;s 39 Longview Drive,Queensbury Town, New York 12804 W Manner of Death ©Natural Cause ❑Accident 1=1 Homicir' Suicide ❑Undetermined ❑Pending Circumstances Investigation Q Medical Certifier Name rifle Mary Stein NP — - Address 9 Carey Road,Queensbury Town,New York 12804 Death Certificate Filed District W+.,ib'r Register Number City,Town or Village Queensbury 5657 219 ❑Burial Date Cemetery,Crematory or Facility Name 11/13/2021 Pine View Crematory 11 Entombment Address X❑Cremation Queensbury Town,New York ❑Donation Z ❑Removal Date Place Removed and/or and/or Held H Hold Address N 0 d Date Point of N1 ❑Transportation a by Common Shipment Carrier Destination ❑Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596 Address 407 Bay Rd,Queensbury,New York 12804 3 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped,If Other than Above Address W O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 11/12/2021 Registrar of Vital Statistics CaroCine1fildegarde Bar6er(ECectronicaCCySigned) (signature) District Number 5657 Place Queensbury, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: I- �' WDate of Disposition (a HSh.( Place of Disposition A7,,,,t,/,... 61".0r` 2 (address) W NCC (section) A (lot number) (grave number) 8 Name of Sexton or Person in Charge f Premises n L_ , Y- z (pleaasprint) / �r W Signature /� Title L Pry' `L L _ DOH-1555(07/18)p I.of 2 15329 Public Health Law Sec. 4145(2b) Receipt Human remains of • delivered on , 20 -its iv tF yi Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License# 1