Dejnozka, Henry i - V C.,
A ysb
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section `•.=� .; Burial - Transit Permit
Name First Middle }- Last Sex
Henry .„ Dejnozka Male
Date of Death Age If Veteran of U.S. Armed Forces,
06 / 06 / 2018 94 War or Dates N/A
}- Place of Death Hospital, Institution or
ZCity, Town or Village Greenfield Street Address 315 Coy Road
8 Manner of Death®Natural Cause Accident Homicide E Suicide �Undetermined �Pending
W. Circumstances Investigation
la Medical Certifier Name Title
iQ Roland T. Phillips MD
Address
6 Care Ln, Saratoga Springs, NY 12866
iiiii Death Certificate Filed District Number Register Number
' `: City, Town or Village Greenfield
giii ElBurial Date Cemetery or Crematory
06 / 07 / 2018 Pine View Crematory
MO Entombment
Address
Cremation gueensbury, NY
;..;.,. Date Place Removed
❑Removal and/or Held
and/or Address
CA
Date Point of
Q Transportation Shipment
1. by Common Destination
Carrier
mi
ilii;iiQ Disinterment Date Cemetery Address
,Q Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Compassionate Funeral Care 00364
Address
sa 402 Maple Ave., Saratoga Sp., NY 12866
iliiigi Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
iro
Permission is hereby granted to dispose of the human remains described above as'ndicated.
<;IN Date Issued (,-') I$ Registrar of Vital Statistics S ,�
(signature)
liii
District Number 1.\C�51 Place Greenfield , New York
eg
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
400.
fli Date of Disposition (4ii irg Place of Disposition ,{2,44„ 46,1I9�.
Si (address)
la
f/
CC (section) /(lot number) (grave number)
eiName of Sexton or Person i.p Charge of Pre ises /1'�� s�w..�>
Z it (pl ase print) •
Signature Title /► P/D'�
1
(over)
DOH-1555 (02/2004)