Domaszewics, Mary NEW YORK STATE DEPARTMENT OF HEALt r,,, //
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Mary H. Domaszewicz Female
Date of Death Age If Veteran of U.S.Armed Forces, '
I. February 28, 2006 53 War or Dates
Z Place of Death Hospital, Institution or
W City,Town,or Village Saratoga Springs Street Address Saratoga Hospital
G Manner of Death E] Natural Cause ❑ Accident 0 Homicide 0 Suicide 0 Undetermined ❑ Pending
W Circumstances Investigation
Medical Certifier Name Title
W Dr. Michael Keefe, M.D. Dr.
0 Address
1 West Ave. , Saratoga Springs, NY 12866
Death Certificate Filed Distric umber Register Number
City,Town or Village Saratoga Springs O( q Z
❑Burial Date Cemetery or Crematory
March 2, 2006 Pine View Crematory
❑Entombment Address
E Cremation Quaker Road Queensbury, NY 12804
Date Place Removed
0 ❑Removal and/or Held
and/or Address
I" Hold
0 Date Point of
0 0 Transportation Shipment
d by Common Destination
Carrier
Date Cemetery Address
6 0
Disinterment
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home 01142
Address
82 Broadway, Fort Edward, New York 12828
F= Name of Funeral Firm Making Disposition or to Whom
2 Remains are Shipped, If Other than Above
X
aAddress
Permission is hereby granted to dispose of the human rem ' c ed atry indica .
Date Issued 3 - c �Ce) Registrar of Vital Statistics
(( (signature)
District Number '"C 5 Place Saratoga Springs,New York
F. I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2
Ill Date of Disposition 03/02/2006 Place of Disposition pine View Crematory
W (address)
N
0 (section) lot number) f (grave number)
0 Name of Sexton or Person in Charge of Premises �,.i/,�,��� R 8 `
W please print)
Signature Title
r.,,,,p4,-(96z _
(over)
DOH-1555 (02/2004)