Derussha, Daniel David 41 ‘v 9v
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NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Daniel David Derusha Male
Date of Death Age If Veteran of U.S.Armed Forces,
08/25/2023 39 Years War or Dates
F Place of Death Hospital,Institution or
WCity,Town or Village Schenectady Street Address 831 Seneca Street,Schenectady,New York 12308
p Manner of Death 0 Natural Cause Accident Homicide Suicide Undetermined Pending
ILI
0 Circumstances Investigation
G Medical Certifier Name Title
Nadarajah Balasubramaniam ME
Address
1101 Nott Street,Schenectady,New York 12308
Death Certificate Filed City Of Schenectady District Number Register Number
City,Town or Village 4601 683
BurialF
Date Cemetery,Crematory or Facility Name
08/28/2023 Plne View Crematory
Entombment Address
nCremation Queensbury Town, New York
Donation
0❑Removal Date Place Removed
and/or and/or Held
H Hold Address
CO
0
d Date Point of
U)❑Transportation
p by Common Shipment _`
Carrier Destination
ElDisinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M B Kilmer Funeral Home-Argyle 01077
Address
123 Main St,Argyle,New York 12809
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped,If Other than Above
i Address
CC
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 08/28/2023 Registrar of Vital Statistics Samanta R.Mykoo(Electronically Signed)
(signature)
District Number 4601 Place City Of Schenectady
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z I —
W Date of Disposition �2�,Qp�3 Place of Disposition B�P �r e� Cr��I►1�t�C-
(address)
LU
N CC (section) (lot number (grave number)
0 Name of Sexton or Person in Charge f PremissiCJY's1JOoir) da
Z (please p mt)
W Signature Title pferejec—
DOH-1555(07/18)p 1 of 2
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1 I.. 1 i 7 2---,,'0
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Public Health Law Sec. 4145(2b)
Receipt
Human remains of , , ' .''' delivered on , 20
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Pine View Cemetery , .
Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#
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