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Watulak, Beverly 3 *4t /13'L1. NEW YORK STATE DEPARTMENT OF HEALTH t Vital Records Section Burial - Transit Permit w Name First Middle Last Sex Beverly D.Watulak Female I£ Date of Death Age If Veteran of U.S.Armed Forces, '' 04/24/2018 80 Years War or Dates i x Place of Death Hospital, Institution or 1( City, Town or Village Saratoga Springs Street Address Saratoga Hospital • Manner of Death Undetermined Pending ©Natural Cause �Accident �Homicide �Suicide � � 1- Circumstances Investigation Medical Certifier Name Title Desmond Delgiacco MD 40• 1 Address 211 Church St,Saratoga Springs,New York 12866 • Death Certificate Filed District Number Register Number i.4 City, Town or Village Saratoga Springs 4501 249 E1 Bu ial Date Cemetery or Crematory Yvj 04/26/2018 Pineview Crematorium h ❑Entombment Address §e.giCremation Queensbury Town, New York Date Place Removed ❑Removal and/or Held and/or Address Hold Date Point of Q Transportation Shipment t by Common Destination Carrier tt.Q Disinterment Date Cemetery Address El Reinterment Date Cemetery Address • , Permit Issued to Registration Number in Name of Funeral Home Densmore Funeral Home Inc 00448 To Address 7 Sherman Ave,Corinth,New York 12822 • R Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above �...." Address ro Permission is hereby granted to dispose of the human remains described above as indicated. • Date Issued 04/25/2018 Registrar of Vital Statistics John PTratick Efectrontca1tySigned Pil (signature) Iv District Number 4501 Place Saratoga Springs, New York Sn I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: ' Date of Disposition Y21,Id Place of Disposition ,9•J ,, L ' -f (address) i J (section) ji(lot number) (grave number) l Name of Sexton or Person in Char a of Premises N"4 11 (pase print s Signature Title trZt enlIVI (over) DOH-1555(02/2004)