Dziemianowicz, Alice NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Biostatistics -Vital Records Section
11 Name First Middle Last Sex
Alice Dziemianowicz Female
.::,.Date of D
Bath ii Age : If Veteran of U.S.Armed Forces,
----: 7-9-88 57 yrs.? War or Dates no
Place of Death Hospital, Institution or
l City,Town or Village of Glens Falls Street Address Glens Falls Hospital
Cause of Death
::t
Hepatic Coma
Au Medical Certifier Name Title
XR Daniel Way, MD....... Medical Physician
Address
c/o Warrensburg Health Center, Warrensburg, NY 12885
Death Certificate Filed ii. District Number Register Number
City,Town or Village _ of Glens Falls i� 7
': Date 7-12-88 Cemetery or Crematory
s Burial Pine View Cemetery
Address ......:..::.:..:::.:.:::.::.:.......................................:...................................................................................
❑Cremation
Town of Queensbury, NY
.............................................................................................................
Zi Date Place Removed
<O ❑ Removal and/or Held
_.
Address
w.
<ts ' Date ..........Point.of................................................................................................................................
U)I ['Transportation by ' Shipment
Common Carrier
Destination
.........................-......................... .... .......................................................................................................
❑ Disinterment ii Date Cemetery Address
...........................................:.::.Date:::::..................................................... .......................................................................................................
El Reinterment Cemetery Address
Permit Issued to Registration Number
Name of Funeral Firm Regan & Denny Funeral Home 02883
Address::::::.............................................................................................................................................................................................................................................
Quaker Road, Glens Falls, NY 12801
iig :.Name.of.Funeral..Firm Makiin: brip:.sition:orto Whom......................................................................................................
................................................................................................::::::
g po 0 0
iisi Remains are Shipped, if Other than Above
::t�i
Address
::t>w:
.:::::..............................................................................................................................................................................................................................................................................
Permission is hereby granted to dispose of the huma re ins scribed ove as indicated.-----
Date Issued 1— .. Pi T Registrar of Vital Statistics ^� " _ E'�-`,
rj ignature)
�� _.':>: District Number �.5 / Place < —"``� lcd�i � /
I certify that the remains of the decedent identified above were disposed of' accordance with this permit on:
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�Z: Date of Disposition 7/Z—SAP Place of Disposition r iv-, v i t° C.) CC �r e Sl il
(address)
w; aN'c •weo— d
(section) (lot number) (grave number)
p; Name of Sexto Person in Charge of Premises k o cI ry e Li Cr-. VV.l Q S'
k
Z (please print)
Au Signature IiO�fn_A._ �!) - {i1-rr-o.t.A Title S ��j'".
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DOH-1555(9/86)p 1 of 2(formerly VS-61)