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Malkowski, John NEW YORK STATE DEPARTMENT OF HEALTH . ..\ Burial - Transit Perm,Vital Records Section Name First Middle Last Sex John P. Malkowski Male Date of Death Age If Veteran of U.S. Armed Forces, ` April 14, 2011 57 War or Dates Place of Death Hospital, Institution or City, Town or Village Argyle Street Address 746 Route 47 $7Ce Manner of Deathrn Lvi Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending Circumstances Investigation Medical Certifier Name Title Robert Sponzo, Dr. Address 102 Park St. Glens Falls, NY 12801 Death Certificate Filed District Number Register Number City, Town or Village 5?) `J—b c2 5- 5 f ❑Burial Date Cemetery or Crematory April 15, 2011 Pine View Crematory ❑Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed ❑ Removal and/or and/or Held Hold Address Date Point of ❑Transportation Shipment by Common Destination Carrier Disinterment Date Cemetery Address ,. A ❑ Re nterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home M. B. Kilmer Funeral Home 01096 Address 123 Main St., Argyle NY 12809 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above _ Address Permission is he eby ranted to dispose of the human re 'ns describe above as indicated. Date Issued /S ) Registrar of Vital Statistics ��� ,1, ;�,ir 35— I (signature) District Number S7 Place lO).tl L., dk ,,.., I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: 9a"g .' Date of Disposition 04/15/2011 Place of Disposition Quaker Road Queensbury,NY 12804 (address) a (section) � (lo ber) (grave number) Name of Sexton or P son in Charg of Premises {,�i �� �e„in `� (please print) "* Signature [ L Title (please (over) DOH-1555 (02/2004)