Przybylo, Rita i N
NEW YORK STATE DEPARTMENT OF HEALTH '71
Vital Records Section Burial - Transit Permit
44 Name First Middle Last Sex
Rita Helen Przybylo Female
;,:A Date of Death Age If Veteran of U.S. Armed Forces,
08/30/2018 88 Years War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death 0 Natural Cause El Accident El Homicide ID Suicide El Undetermined n Pending
Circumstances Investigation
Medical Certifier Name Title
Michael Miles MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
tz.r City, Town or Village Glens Falls 5601 419
�G ❑Burial Date Cemetery or Crematory
09/04/2018 Pineview Crematorium
❑Entombment Address
®Cremation Queensbury Town, New York
nx Date Place Removed
❑Removal and/or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment
by Common Destination
Carrier
"�Q Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
v Name of Funeral Home Radloff Funeral Home Inc 01425
; , Address
136 Warren St,Glens Falls,New York 12801
Name of Funeral Firm Making P
Dis osition or to Whom
: Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
11,
Date Issued 09/04/2018 Registrar of Vital Statistics Ro6ertA Curtis(ECectronicaay Signed)
1-
Z (signature)
` District Number Place
5601 Glens Falls, New York
`' I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition el)if lit Place of Disposition ?.AL t:rw1 e-.
(address)
4.
(section) (lot numb /) (grave number)
c Name of Sexton or Person in Charge f Premises l r,+f Jl4 l
(please print)
r Signature > Title YZt1i N
(over)
DOH-1555(02/2004)