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Sikorak, Doris Marilyn
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Doris Marilyn Sikorak Female Date of Death Age If Veteran of U.S.Armed Forces, 12/24/2019 93 Years War or Dates �.. Place of Death Hospital,Institution or Z City,Town or Village Glens Falls Street Address Glens Falls Hospital 13 W Manner of Death Undetermined Pending © Natural Cause Accident ❑Homicide ❑Suicide g W Circumstances Investigation W Medical Certifier Name Title Nawed Siddiqui MD Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Glens Falls 5601 552 Burial Date Cemetery,Crematory or Facility Name 12/27/2019 Pine View Crematorium Entombment Address X❑Cremation Queensbury Town,New York ❑Donation z Removal Date Place Removed and/or and/or Held F-N Hold Address O IL Date Point of fA ❑Transportation p by Common Shipment Carrier Destination Disinterment Date Cemetery Address ❑Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home Inc 00281 Address 68 Main Street,P.O.Box 67,Hudson Falls,New York 12839 Name of Funeral Firm Making Disposition or to Whom _H Remains are Shipped,If Otherthan Above Address IM W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 12/27/2019 Registrar of Vital Statistics q�96ertAndrety Curtis(Efectronically Signer /signature/ District Number 5601 Place Glens Falls, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: H Z Date of Disposition Place of Disposition dCtj.�— � /address) W N (section) )lot number) (grave number) IIM G Name of Sexton or Person in Charge of Premises please print) Z W Signature Title DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) 013184 Receipt f Human remains of delivered on 201 Pine View Cemetery Representing the funeral home named on burial.permit Official Funeral Directors Reg.or License#