Kosloske, Louis NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
`'' Name First Middle Last Sex
°
Louis A./ Kosloske Male
sip Date of Death Age If Veteran of U.S. Armed Forces,
July 9,2016 76 War or Dates
3 Place of Death Hospital, Institution or
2- City, Town or Village Glens Falls Street Address Glens Falls Hospital
lit
Manner of Death X Natural Cause Accident n Homicide Suicide Undetermined I I Pending
ill, Circumstances Investigation
la Medical Certifier Name Title
0 Frances Bollinger MD
Address
Glens Falls,NY
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 I--i 6
❑Burial Date Cemetery or Crematory
Pine View Crematory
❑Entombment July 11,2016
Address
EI Cremation 21 Quaker Rd., Queensbury,NY 12804
Date Place Removed
Z
—Removal and/or Held
and/or Address
Hold
co
O Date Point of
N Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
n Renterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Alexander-Baker Funeral Home 00037
a' Address
`,,% 3809 Main Street,Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
i' l Remains are Shipped, If Other than Above
Address
ILI-
L Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 7-11-16 Registrar of Vital Statistics Wc;t...92
(signatu )
District Number S 6C j Place Glens Falls,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z p
ui Date of Disposition 7113/(6 Place of Disposition 41 0 le." `s4-41-0ri,..
W (address)
co
ce
0 (section) (lot number) ( (grave number)
QName of Sexton or Person in Charge of Premises �fh.1 Stfr P
Z lease print)
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Signature a .1") Title C(4 f(1
(over)
DOH-1555 (02/2004)