Wachowski, Theresa NEW YORK STATE DEPARTMENT OF HEALTH r
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Theresa M. Wachowski Female
Date of Death Age If Veteran of U.S. Armed Forces,
February 15,2017 80 War or Dates
Place of Death Hospital, Institution or
IZ City, Town or Village Plattsburgh Street Address UVM Health Network- CVPH
p Manner of Death X Natural Cause I I Accident Homicide Suicide Undetermined Pending
w Circumstances Investigation
w Medical Certifier Name Title
G Vlaqimiu Sabayev
Address
75 Beekman Street Plattsburgh,NY 12901
Death Certificate Filed District Number Register Number
City, Town or Village �/
❑Burial Date Cemetery or Crematory
February 16, 2017 Pineview Crematory
❑Entombment Address
M Cremation I , Queensbury, NY
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
U)
0 Date Point of
cnTransportation Shipment
Q by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Edward L. Kelly Funeral Home 00519
Address
, Schroon Lake, NY 12870
Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped, If Other than Above
g Address
IY
IL
O
Permission is hereby granted to dispose of the human rem s described above as in cated. �f�
Date issued 2/16/17 Registrar of Vital Statistics G ,j'f'...f„ ��� 7/
(signature) (�
District Number Place
I certify that the remains of the decedent identifi above re disposed of in accordan With this permit on:
WDate of Disposition 2.111 ill Place of Disposition 'for V44.4.-.0 (rrrog t®!',,—
E (address)
W
co
p0 (section) //(lat number) ( (grave number)
Name of Sexton or Person in Charge of Premises (�trvI t, 31:04tP"
Z y% (pI ase print)
Signature /1,1 -At Title 1 Z 1)L
(over)
DOH-1555 (02/2004)