Kozloski, Frances NEW YORK STATE DEPARTMENT OF HEALTH g
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Frances C. Kozloski Female
Date of Death Age If Veteran of U.S. Armed Forces,
October 12, 2016 98 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Queensbury Street Address The Stanton Nursing& Rehab Center
Manner of Death Natural Cause 0 Accident I I Homicide Suicide ❑Undetermined n Pending
Circumstances Investigation
Medical Certifier Name el( nOrd0 , � �G �_ Title
MO
Address '
Death Certificate Filed a ` � � District Number Register Number
City, Town or Village k J Q Vr1J0 Vi VI �j(p5'1 1 t 4
❑Burial Date yJf Cemetery or Crematory
October 13, 2016 Pine View Crematorium
❑Entombment Address
®Cremation
Date Place Removed
Z ElRemoval and/or Held
and/or Address
H Hold
N
0 Date Point of
O.
❑Transportation Shipment
'p by Common Destination
Carrier
IIIDisinterment Date Cemetery Address
Reinterment Date Cemetery Address
'1 Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
• Remains are Shipped, If Other than Above
2. Address
WI
`` Permission is hereby granted to dispose of the human re des, ' e a in 'cated.
Date Issued I p- I a-I 1p Registrar of Vital Statistics ,..,0 bt_
(signet
District Number SUcl Place 4 Duu it,,,
I certify that the remains of the decedent identified ab were disposed of i accorda ce with this permit on:
wDate of Disposition p I PIM/, Place of Disposition a^t �,. Cwr r,a4V. .
g (address)
w
Cl)
ct (section) (lot number) (grave number)
QName of Sexton or Person in Charge of Premises lAr.artke .ci,riW
Z ( lease print)
W Signature Li( 4Title l 'MR
(over)
DOH-1555(02/2004)