Slofsky, Keith :. •
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Keith F. Slofsky Male
Date of Death Age If Veteran of U.S. Armed Forces,
May 9, 2017 61 War or Dates
Place of Death Hospital, Institution or
WCity, Town or Village Queensbury Street Address 27 Danford Court
O Manner of Death n Natural Cause piAccident Homicide Suicide n Undetermined n Pending
Circumstances Investigation
w Medical Certifier Name Title
O Gerald F Abess
Address
3 Irongate Center
Death Certificate Filed District Number Register Number
City, Town or Village Queensbury 5657 C2p2
®Burial Date Cemetery or Crematory
May 15, 2017 Pine View Cemetery
❑Entombment Address
E Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
ZZ n Removal and/or Held
and/or Address
H Hold
CO
O Date Point of
N Transportation Shipment
a by Common Destination
Carrier
n Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
• Addressft
(-------)
iai
Permission is hereby granted to dispose of the human ins cresc ' d a as i cated.
Date Issued 'S—I I—0.011 Registrar of Vital Statistics Q
(signs ure
District Number 5657 Place Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w Date of Disposition 5/1 5/2 0 1 flace of Disposition Pi n e v i Pw CP u t. c,ry 21 Quaker Rd
W
U) 4 Erie 4 —E
(section) (lot number) (grave number)
pName of Sexton or Person i Ch rge of Premises Connie L. Goedert
Z (please print)
W Signature & , _, Title
(over)
DOH-1555(02/2004)