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Kocsis, Gheorge /01 NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Vital Records Section • • igii Name First Middle Last Sex Gheorge Kocsis Male <` Date of Death Age If Veteran of U.S. Armed Forces, lit„. August 9, 2017 89 War or Dates .. Place of Death Hospital, Institution or City, Town or Village Glens Falls Street Address Glens Falls Hospital 2 Manner of Death .Natural Cause ❑Accident ❑Homicide Suicide ri Undetermined n Pending 14 Circumstances Investigation 1 Medical Certifier Name Title Suzanne Bergin Address iiiii3167 Main Street,Warrensburg,NY 12885 iiiiDeath Certificate Filed District Number Registerier ii!..,.. �`` City, Town or Village Glens Falls 5601 ❑Burial Date Cemetery or Crematory August 11,2017 Pine View Crematorium ❑Entombment Address ©Cremation 51 Quaker Road, Queensbury,NY 12804 Date Place Removed ZO ❑Removal and/or Held and/or Address H Hold Cl) O Date Point of Transportation Shipment a by Common Destination Carrier Disinterment Date Cemetery Address ❑Reinterment Date Cemetery Address >_? Permit Issued to Registration Number '` Name of Funeral Home Regan Denny Stafford Funeral Home 01443 :f" :l? Address 11 53 Quaker Road, Queensbury,NY 12804 } Name of Funeral Firm Making Disposition or to Whom `:: Remains are Shipped, If Other than Above , . Address 1f 'r- Permission is hereby granted to dispose of the human remains described above as indicated. f. 4 1 Date Issued S( (1 1 2-0)7 Registrar of Vital Statistics WCv\A ignature) •ff.r (JC ;.;;� District Number 5601 Place Glens FallsI f..h 1 I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z W Date of Disposition _ $I IS in Place of Disposition f? (Jw �,,,4o--.. 2 (address) W Cl) Qre (section) f lot clamber) (grave number) Name of Sexton or Person in Charge of remises '&� � �(�` Z al (plea a print)IL h�Signature _ -I Title •1,'�m�(j (over) DOH-1555(02/2004)