Atamanchuk, William Stephen NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle last Sex
William Stephen Atamanchuk Mete
Date of Death Age If Veteran of U.S.Armed Forces,
10/06/2022 57 Years War or Dates
H Place of Death Hospital,Institution or
Z City,Town or Village Queensbury Town Street Address 543 Aviation Road 111,Queensbury Town,New York 12804
2+ Manner of Death ❑Natural Cause ❑Accident 0Hornicide Suicide ElUndetermined R1Pending
W Circumstances Investigation
W Medical Certifier Name Title
G Connie Goedert Coroner
Address
1400 St Route 9,Lake George Town,New York 12845
Death Certificate Filed Town Of Queensbury District Number Register Number
Cit E,Town or Vill a 5657 148
Burial Date Cemetery,Crematory or Facility Name Vie
w Pine Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
0❑Removal Date Place Removed
and/or and/or Held
NHold Address
0
O. Date Point of
CO❑Transportation Shipment
p by Common
Carrier Destination
Disinterment
Date Cemetery Address
Date Cemetery Address
OReinterment
Permit Issued to Registration Number
Name of Funeral Home Maynard 0 Baker Funeral Home 01130
Address
11 Lafayette St,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
1.— Remains are Shipped,If Other than Above
2 Address —
CC
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 10/12/2022 Registrarof Vital Statistics Camatte.7a4gart4Bar{rr'(Ekartmr 4irm4
(s/gnelure)
District Number 5657 Place Town Of Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on;
Date ofDisposition /0 Placeof Disposition IZ 1 Z2 sposon
W `(�' t‘i(
2 �addr
W
to Q (section) lot number) (gra le number)
8 Name of Sexton or Person in Charge of Prem. 4' �Pe punt/ Sl^^ll-
W Signature _ Title r rn/
DOH 1555(07/18)p t of 2
r .
1„ I
Public Health Law Sec. 4145(2b)
Receipt
Human remains of • delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License# • 'lr �