Ardzinski, Thomas e ' 1
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit t 37
Vital Records Section
Name First Middle Last Sex
THOMAS A. ARDZINSKI MALE
Date of Death Age If Veteran of U.S.Armed Forces,
4 01/08/2018 61 War or Dates
[•.. Place of Death - Hospital, Institution
Z_ City ,Town or Village City of Albany or Street Address ALBANY MEDICAL CENTER
Manner of Death ❑ Natural ❑ Accident ❑ Homicide ® Suicide ❑ Undetermined ❑ Pending
LU Cause Circumstances Investigation
ui Medical Certifier Name Title
p MUHAMMAD IMTIAZ MD
Address
43 NEW SCOTLAND AVE ALBANY NY 12208
Death Certificate Filed District Number Register Number
City,Town or Village City of Albany 101 0065
Date Cemetery or Crematory
❑ Burial 01/10/2018 PINEVIEW CREMATORY
❑ Entombment Address
® Cremation QUEENSBURY, NY
Date. Place Removed
Z` Removal and/or Held
Q ❑ and/or Address
1— Hold
N
0 Date Point of
a, Transportation Shipment
U) ❑ By Common Destination
15 Carrier
Date Cemetery Address
El Disinterment
Date Cemetery Address
❑
Reinterment
Permit Issued To Registration Number
Name of Funeral Home COMPASSIONATE FUNERAL CARE INC 00364
F:, Address
402 MAPLE AVE., SARATOGA SPRINGS, NY 12866
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
a Address
al Permission is hereby granted to dispose of the human remains described above as indicated.
IL
01/09/2018
Date w.e
Issued Registrar of Vital Statistics
(signature)
District Number 101 Place City of Albany, NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition 7'ii/i .0 Place of Disposition /�i n Q V l'Cc.J 6-re-044 /
to (address)
W
ce (section) (lot number) (grave number)
Z Name of Sexton or Person in Charge of Premises a^' `4-,i1 l�4. a f.
(please print)
Signature ,--,4', Title
/L'�4./i/
(over)
DOH-1555 (02/2004)