Pawluk, Gary % r -713
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Gary Edward Pawluk (Y10l
Date of Death Age If Veteran of U.S. Armed Forces, , vllii
09 / 06 / 2018 72 War or Dates I LA Cpt, -
i4 Place of Death Hospital, Institution or
ZCity, Town or Village Malta Street Address 1602 Cheltenham Court
a Manner of Death®Natural Cause E Accident E Homicide E Suicide ❑Undetermined 0 Pending
US Circumstances Investigation
43
ul Medical Certifier Name Title
q Abdus Rahn MD
Address
350 S Broadway Hicksville, NY 11801-5006
Death Certificate Filed District Number Register Number
City, Town or Village Malta y5oC) 3�
❑Burial Date Cemetery or Crematory
09 / 07 / 2018 Pine View Crematory
[« DEntombment Address
ECremation Queensbury, NY
Date Place Removed
❑Removal and/or Held
and/or Address
WS
Hold
Date Point of
iE]Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
>< Permit Issued to Registration Number
18 Name of Funeral Home Compassionate Funeral Care 00364
Address
402 Maple Ave. , Saratoga Sp. , NY 12866
liiiiii Name of Funeral Firm Making Disposition or to Whom
4.,*,,,, Remains are Shipped, If Other than Above
Address
5
:-. Permission is h reb granted to dispose of the human ren{aii s descri boy as icated.
Date Issued C\ \ q..CA Registrar of Vital Statistics i'
(signature)
District Number y'j(c0 Place Malta , New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
taDate of Disposition 1/phi Place of Disposition e.iu,.- �mft0rI✓'
Z (address)
CC (section) p(lot number) c (grave number)
QName of Sexton or Person in Charge of Premises - `/Art*, �.rt
2: (pl print) •
Signature A Title
(over)
DOH-1555 (02/2004)