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Averinos, Michael Peter 01/05/2022 WED 13: 21 FAX l 001/001 �'vfr NEW YORK STATE DEPARTMENT OF HEALTH Vital Reoords Section Burial - Transit Permit Name First Middle Last I Sex Michael Peter Averinos Male Date of Death Age If Veteran of U.S.Armed Forces, f"3 01/01/2022 _ 50 years War or Dates :'. Place of Death Hospital, Institution or Cit , T r - 7lens Falls Street Address Glens FaILa_Hospitel Manner of Death 0 Natural Cause ❑Accident ❑Homicide ❑Suicide Undetermined 0 Pending Circumstances Investigation M d ll Certifier Name Title 0 Sean Bain — M D Address . • • 100 Park St. Glens Falls, N Y . D,eafh Certificate Filed District Number. . : •. . .. Register.Nu,mber,...,; ; %i. .City T DCD(QS�4 E :.r �( • Gl ns Falls . • 5601 - ©Burial Date Cemetery or Crematory ❑Entombment 01/06/2022 _ Pine View Cemetery Address ?'"s❑Cremation Queensbury, NY 12804 v Date Place Removed in Removal .. and/or Held _ • and/or Address . Hold . Date Point of ❑Transportation — Shipment • by Common Destination • `:aC,arrier • 't'i;, •. , - ,.<.• Cemeteryes "``Q Disinterment • Date Address Date Cemetery Address ❑Reinterment 1: Permit Issued to Registration Number 1. Name of Funeral Home Baker Funeral Home . . 01130 -Address. • - 11 Lafayette Street — '* Name,of Funeral Firm Making Disposition or to Whom MtRemains are Shipped, If Other than Above _Address ice _ _ Permission is hereby granted to dispose of the human remain ascribed above as Indicated., ` • s e Registrar of Vital Statistics • • rs Date Issued 01/05/2022 g (sign e) • R:: District Number 5B0.1• Place Gle9„ Falls _. .te r ''':. I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: `ael pt>j .Dee of Disposition ,•L.as Place of Disposition ' (address) L • - on) • (lot number (grave number) Qz1 Name of Sexton or Person in Char pre esl e please print) <::5Signature Pe -4- • Tito esi —� . (over) DOH-1555,(02/2004) •' Public Health Law Sec. 4145(2b) 012894 Receipt Human remains of - 1. _, delivered on /- f , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License# ? ' '- AVERINOS NAME Michael Peter Averinos Age: 50 Lot Owner: Michael Averinos Lot# Horicon 5H Grave# 1 Case: Concrete Died: 1 /1 /2 0 2 2 Interred: 1 /6/2 2 Funeral Home: Baker FH Cemetery: Pine View