Kurak, Madelyn NEW YORK STATE DEPARTMENT OF HEALTH it S yb
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Madelyn M. Kurak Female
Date of Death Age If Veteran of U.S. Armed Forces,
11 / 18 / 2016 102 War or Dates N/A
}= Place of Death Hospital, Institution or
WCity, Town or Village Saratoga Springs Street Address Wesley Health Care Center
t3 Manner of Death f Natural Cause 0 Accident 0 Homicide 0 Suicide -1 Undetermined 7 Pending
Circumstances Investigation
Ca
ILI Medical Certifier Name Title
Q Rick D. Teetz MD
Address
1134 NY-29, Greenwich, NY 12834
Death Certificate Filed District Number Register Number
City, Town or Village Saratoga Springs y 5in
' OBurial Date Cemetery or Crematory
Entombment / / /c9 )c Pine View Crematory
Address
iali ECremation Queensbury, NY
Date Place Removed
Z❑Removal and/or Held
Pen and/or Address
b Hold
VA
0 Date Point of
❑Transportation Shipment
Et by Common Destination
Carrier
Q Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
giIi
Permit Issued to Registration Number
Name of Funeral Home Compassionate Funeral Care 1 00364
Address
_>'' 402 Maple Ave., Saratoga Sp. , NY 12866
Name of Funeral Firm Making Disposition or to Whom
4. Remains are Shipped, If Other than Above
2 Address
LEII
Permission is hf2..
reb granted to dispose of the human rem cr' ed ably indicat .
Date Issued 1 Registrar of Vital Statistics
(signature)
District Number I Place Saratoga Springs , New York
.A: I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Ui Date of Disposition II/te hi, Place of Disposition frwt..J (",G ,.,.
2 (address)
Ili
0
lr (section) /lot number) (grave number)
Q /1
II Name of Sexton or Person in Charge of Pr mises '. ll t�s1 r .iSmlt
z a (ple se print) .
t„ •Signature Title <cAft
(over)
DOH-1555 (02/2004) ,