Loading...
Kolysko, Paul • i # c/b NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex Paul Vincent Yolycko Male Date of Death Age If Veteran of U.S. Armed Forces, 06/26/2016 69 yrs. War or Dates 1965 - 19613 .14 Place of Death Town of Hospital, Institution or tuZ City, Town or Village Ti conrier a Street Address 112 �it^on RManner of Death©Natural Cause 11Accident 0 Homicide ❑Suicide ifUndetermmecP"1 Pending W Circumstances Investigation la Medical Certifier Name Title Glen Chapman M_D_ Address 102 Race Track Road, Ticonderoga, NY 12883 Death Certificate Filed Town of District Number Register Number 3 pp City, Town or Village Ticonderoga 1564 i gi ❑Burial Date Cemetery or Crematory 06/28/2016 Pine View Crematory i' ❑Entombment Address gi®Cremation Queensbury, New York Date Place Removed Z❑Removal and/or Held and/or Address I'` Hold t 0 Date Point of il ❑Transportation Shipment G by Common Destination Carrier ❑Disinterment Date Cemetery Address ❑Reinterment Date Cemetery Address M. Permit Issued to Registration Number iiiiiii Name of Funeral Home Wilcox & RPgan funr.ral__hrImP 01821 Ai Address 11 Algonkin St., Ticonderoga, New York 17883 Mi Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above ;; Address t Iu fl" Permission is hereby granted to dispose of the human re in described ve s in icated. Date Issued 6/28/2016 Registrar of Vital Statistics (ski nature) District Number 1564 Place Town of Ticonder a I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: I Date of Disposition 0 11,11 (, Place of Disposition ?rcu✓ `fernr-44.-, a (address) LU VI CC (section) (lot number) (grave number) AellName of Sexton or Person in Charge of Premises �l 2 (pl ase print) E Signature Title � `"� (over) DOH-1555 (02/2004)