Pliscofsky Sr., Anthony .4-
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NEW YORK STATE DEPARTMENT OF HEAL7F! - � Burial _ Transit Permit
Vital Records Section
Name First Middle Last Sex
Anthony J Pliscofsky Sr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
11/21/2017 87 Years _ 'A'ar or Dates 1947-52
Place of Death coital, Institution or
1 City, Town or Village Glens Falls .creet Address Glens Falls Hospital
Manner of Death IX Natural Cause El Accident 0 Homicide 0 Suicide Undetermined El Pending
Circumstances Investigation
r Medical Certifier Name Title
,,' Sarah Walton PA
iss Address
4:- 100 Park St,Glens Falls,New York 12801
it Death Certificate Filed District Number Register Number
fil City, Town or Village Glens Falls 5601 601
Al.ri
Burial Date Cemetery or Crematory
11/22/2017 Pineview Crematory
1❑Entombment
z Address
®Cremation Queensbury Town, New York
Date Place Removed
n Removal
. ❑ and/or Held
PO and/or Address
,7. Hold
Date Point of
Q Transportation Shipment
i_ by Common Destination
Carrier
t n Disinterment
Date Cemetery Address
ke FA n Reinterment , Date Cemetery Address
40
Permit Issued to Registration Number
Name of Funeral Home Densmore Funeral Home Inc 00448
AG Address
7 Sherman Ave,Corinth,New York 12822
Ot Name of Funeral Firm Making Disposition 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.
Date Issued 11/22/2017 Registrar of Vital Statistics oe9sertficurus Ekct„mutaysig„ed
(signature)
j,
District Number
_ , 5601 Place Glens Falls, New York
f' I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
;t')± Date of Disposition ///j$jf) Place of Disposition -;,4[li—d /;,evi--._.
(address)
(section) n (lot numbe _ (grave number)
r Name of Sexton or Person in Charge of P mises t1- t..itt
. (please print)
kVc Signature 4 Title int trfiPL
(over)
DOH-1555 (02/2004)