Loading...
Konopka, Theodore ,4 NLVV YUKIKSIAIt UtNAKIMtNi OF HtALIF' 7q� Vital Records Section '' I k Burial - Transit Permit Name First Middle Last Sex Theodore A. Konopka i Male [i Date of D=ath I A e If Veteran_of U.S. Armed Forces, ;. t I j /u 13 j ii ,(�5- Will Of dLCS b Place of Death Hospital, Institution or// ) ,S/4 C-O ae- 111,1 City, Town or Village Chestertc ra Street Address Deceased's Residence -411 Manner of Death r71 Eli Natural Cause Accident 0 Homicide 0 Suicide ri Undetermined ri Pending 441 Circumstances Investigation '4 Medical Certifier Name Title I4' ualc:i Galutu-GruuL7s, Address 102 Paork St Glens Falls, NY 12801 Death Certificate Filed District Numb2C Register Nuppor City, Town or Village �! - ❑Burial Date _ ` �J Ge e/te��/oar Cr/p/m^a^to (00 �y �i / ' ❑Entombment Address gam:®Cremation ( (,): ,,e--2 75j 1/C ��� /sue U " . � Date lace Removed Removal and/or Held and/or Address Hold r ' Date Point of 0 Transportation Shipment by Common Destination Carrier 4,444 n Disinterment Date Cemetery Address A Reinterment Date Cemetery Address OM Permit Issued to Registration Number 00, Name of Funeral Home Barton-McDermott Funeral Home, Inc. 00141 4 Address 44,4444 rule of 1 r.u. bOX 400 i.,iiesteitowri pi T izo i 1 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above ' .k Address an Parmiccinn iic harahv nrantarl to rlicnnca of fha human ra ai acrriharl ahnva AS inrlicatari Date Issued /0- �`'(—lam) Registrar of Vital Statistics 443,44, 'gnature) ---7---` District Number 5-tc "), Place , pWC- CAte S --, I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition JDl ik(t"7 Place of Disposition ,( )...... (r fi-©O� (address) i (section) (lot number) (grave number) < Mama of Cavtnn nr Parcnn in (:harna of Pr icac �tif Sk..4i-- J r ( lease print) W Signature �'L Title atlitaK. (over) R/1.11 ALCL 1l1,1/,1/111A\ Lvl I Ivvv Lv�tt�vvzl