Yanik, Ethel NEW YORK STATE DEPARTMENT OF HEALTH -1
Vital Records Section Burial - Transit Permit
Name First Middle - Last Sex
Ethel M Yanik Female
ffi Date of Death Age If Veteran of U.S. Armed Forces,
04/28/2006 g4 years War or Dates
}• Place of Death Hospital, Institution or
W City, Town olONICXXXXX City Of Glens Falls Street Address Glens Falls Hospital
O Manner of Death❑Natural Cause ❑Accident ❑Homicide 0 Suicide ❑ Undetermined El Pending
U Circumstances Investigation
W Medical Certifier Name Title
Richard S Thomas M. D.
Address
Eden Park Nursing Center Warren St, Glens Falls
Death Certificate Filed District Number Register Number
City, Town oX011(gxXXXX City Of Glens Falls 5801 187
❑Burial Date Cemetery or Crematory
['Entombment Address05/01/2008 Pine View Crematorium
RI OCremation Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
9, ❑and/or Address�;
+V
Hold
)
O Date Point of
❑Transportation Shipment
C by Common Destination
mi Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Densmore Funeral Home, Inc. 00453
Address
7 Sherman Ave. Corinth, NY 12822
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
• Address
tEt
P.` Permission is hereby granted to dispose of the human remains described above as indica
F:ii Date Issued 05/01/2008 Registrar of Vital Statistics �h�.
(signature)
District Number 3-6 0 i Place 6 LN r, .S"`r,_ `\S ) y
1.-.: I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
In Date of Disposition r' 1 t 1. Place of Disposition Pin u I e l rr w‘;tW ' ,,, rt.
2 (address)
till:
0
CC (section) / (lot number) (grave number)
ta Name of Sexton or Person in Charge of Premises ` h r,> . .n nzy Il--
) (please print)
Signature L 1 l,rvy-r-br d Title (- "rn-, r
(over)
DOH-1555 (02/2004)