Zwijacz, Gary i t
-H 4ZZ
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
<> Name First Middle - Last Sex
Gary Zwijacz Male
Date of Death Age If Veteran of U.S. Armed Forces,
07 / 08 / 2017 58 War or Dates Army
}- Place of Death Hospital, Institution or
City, Town or Village Amsterdam Street Address St. Mary's Hospital
LLI
a Manner of Death[El NaturalCause 0 Accident 0 Homicide E Suicide Undetermined 7 Pending
itiCircumstances Investigation
jut Medical Certifier Name Title
Dr. Eyad Aldaas MD
Address
427 Guy Park Ave Amsterdam, NY 12010
ni Death Certificate Filed District Number Register Number
>< City,Town or Village Amsterdam 2EO t 1 (0'1
Iiiii 0Burial Date Cemetery or Crematory
gi 07 / 10 / 2017 Pine View Crematory
i :i8 Entombment Address
aCremation Queensbury, NY
Date Place Removed
❑Removal and/or Held
and/or Address
Hold
Date Point of
Q Transportation Shipment
C by Common Destination
Carrier
Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
!iiiPermit Issued to Registration Number
Name of Funeral Home Compassionate Funeral Care 00364
3 Address
ii 402 Maple Ave., Saratoga Sp. , NY 12866
iiiiiii Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
f
Permission is mi hereby granted to dispose of the human remains • sc '��• : 'iti i , .d.O
< Date Issued 7 I t dp211 Registrar of Vital Statistics "..w
(sign-4ift
District Number 401 Place Amsterdam , New York
- I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2
AM Date of Disposition 1 Poin Place of Disposition fora.) 6M,alprry
(address)
ILI
ilk (section) / (lot number) (grave number)
II Name of Sexton or Person in Charge of P,cemises . l!, tt� t i t
W (pl ase print) .
Signature '�L ✓'' Title ��rMiu _
(over)
DOH-1555 (02/2004)