Levandowsky, Helen VS 61 (Rev. 7/79) New York State Department of Health
BURIAL — TRANSIT PERMIT
Name: First Middle Last Sex
Helen B. Levandowsky Female
Date of Death Age If Veteran of U.S.Armed Forces,War or Dates
Jan. 18 1987 61 No
Place of Death:City,Town or Village Hospital, Institution or Street Address
w Town of Saratoga RD # 1 Box 2450 Caset Rd. Schuylerville, NY
WCauses of Death:
U Acute bronchopnuemonia & Cachexia
A Medical Certifier: J. Yaston MD 2T1 Church Street Saratoga Springs, NY 12866
Death Certificate Filed:City,Town or Village District No. Register No.
Town of Saratoga
0 Burial:
Date Cemetery or Crematory Address
U Cremation: Jan. 19, 1987 Pine Crematorium Town of Queensbury,NY
Z Removal Date Place Removed and/or Held Address
O ❑ and/or Hold:
E-1
thl Date Point of Shipment Destination
0 Transportation by
A. ❑ Common Carrier:
N
QDate Cemetery Address
Disinterment:
El
Reinterment:
Permit Issued To' ame of Funeral Fir A s Registration No.
iiynn Bros. inc. ii Gates Ave. Schuylervi`ie, NY 00829
Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other Than Above:
I—. Address:
A G Permission is hereby granted to dispose of the dead human remains described above indicated
a Date Issued Jan. 19, 1987 2.Q(irc1 I I . ��_4
R strar of Vital Statistics (Signature) "
District No. own of Saratoga, NY
Place
his permit must be completed on back by the person in charge at the place of disposition and filed with the registrar of vital statistics of the city,town or village
where disposition took place.
PUBLIC HEALTH LAW
§4145. Deaths; burial and removal permits; disposition of remains.
1.No person in charge of any premises on which interments,cremations or other disposition of the body of a deceased person are made
shall inter or permit the interment or other disposition of any body unless it is accompaniedpy a burial,cremation or transit permit,as provided
in this article.
2.The funeral director or undertaker shall deliver the burial permit to the person in charge of the place of burial or other disposition,before
interring or otherwise disposing of the body;or shall attach the removal or transit permit to the box containing the body,when shipped by any
transportation company,which permit shall accompany the remains to its destination,where if within this state,it shall be delivered to the
person in charge of the place of burial or other disposition.
3.The person in charge of the place of burial or other disposition shall endorse upon the permit,the date of interment,or cremation or other
disposition over his signature, and shall return all permits so endorsed to the registrar of his district within seven days after the date cf
interment, cremation or other disposition.
4.When burying or otherwise disposing of the body of a deceased person in a cemetery or burial place having no person in charge,the
funeral director or undertaker shall(a)sign the burial or removal permit,giving the date of burial;(b)write across the face of the permit the
words"No person in charge;"and(c)file the burial or removal permit within three days with the registrar of the district in which the cemetery is
located.
5.The person in charge of the place of burial,cremation,or other disposition shall keep a record of all bodies interred or otherwise disposed
of on the premises under his charge,in each case stating the name of each deceased person,place of death,date of burial or disposal,and
name and address of the funeral director or undertaker, which record shall at all times be open to official inspection.
ENDORSEMENT OF SECTON OR PERSON IN CHARGE OF PREMISES.
I certify that the remains were disposed of in accordance with the permit on the reverse side on / / 'c
(Date)
at / I wl � � cc r /9- r / ✓ /34
(Place of disposition and address)
Section Lot No. Grave No.
Signature
Title
C✓��