Kucharczyk, Dolores r
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
`: Name First Middle Last Sex
a Dolores Kucharczyk Female
`r': Date of Death Age If Veteran of U.S. Armed Forces,
Ni June 7, 2017 51 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death n Natural Cause Accident Homicide Suicide Undetermined ❑Pending
Circumstances Investigation
Medical Certifier Name Title
Darci Gaiotti-Grubbs Dr.
Address
102 Park St,Glens Falls,NY 12801
Death Certificate Filed District Number Register Number
`' City, Town or Village Glens Falls 5167 � 46.
❑Burial Date Cemetery or Crematory
❑Entombment June 13, 2017 Pine View Cemetery
Address
®Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z ❑Removal and/or Held
and/or Address
E. Hold
Cl)
O Date Point of
WTransportation Shipment
'p by Common Destination
Carrier
Date Cemetery Address
❑Disinterment
❑Reinterment Date Cemetery Address
00 Permit Issued to Registration Number
" Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Mil
_< Address
53 Quaker Road, Queensbury, NY 12804
rp Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
if
Permission is her by ranted to dispose of the human r ains described bove as i • • -d.
•
r, Date Issued Registrar of Vital Statistics _,�,�-, !�O, (.J'�
(signature)
District Number 5167 Place Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
InDate of Disposition 6111 in Place of Disposition fi U,,,, or....
W (address)
U)
Q: (section) /�// (Ipt number) (grave number)
O Name of Sexton or Person in Charge of P emises 1I r,1 jihmilt
Z (ple a print)
tL Signature li ��� Title �I�EAI�i?J12
(over)
DOH-1555(02/2004)