Adamczyk, James 4
NEW YORK STATE DEPARTMENT OF HEALTH
l S D
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
James T. Adamczyk Male
Date of Death Age If Veteran of U.S. Armed Forces,
08 / 13 / 2016 62 War or Dates
}- Place of Death Hospital, Institution or
ZCity, Town or Village Saratoga Springs Street Address 206 Peerless Lane Apt 206B
g Manner of Death®Natural Cause Accident E Homicide 0 Suicide C Undetermined �Pending
In Circumstances Investigation
iii Medical Certifier Name Title
0 Daniel J. Kuhn Coroner
Address
40 McMaster St., Ballston Spa., NY 12020
giii Death Certificate Filed District Number Register Nurper
City, Town or Village Saratoga Springs
DB aarl'I Date Cemetery or Crematory
08 / 16 / 2016 Pine View Crematory
iiiiiii 0 Entombment Address
liliiq PCremation Queensbury, NY
Date Place Removed
2❑Removal and/or Held
and/or Address
t.O.
Hold
0 Date Point of
siID Transportation Shipment
0 by Common Destination
gi Carrier
'` Disinterment Date Cemetery Address
Pt
Q Reinterment Date ' Cemetery Address
Permit Issued to j Registration Number
Name of Funeral Home Compassionate Funeral Care 00364
€ Address
402 Maple Ave., Saratoga Sp., NY 12866
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
„ _ Address
lL
Permission is hereby granted to dispose of the human remsairrstie)scr' ed a indicat
Date Issued i,S 1 LO Registrar of Vital Statistics •
' si nature
( 9 )
District Number to\ Place Saratoga Springs , New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
ill Date of Disposition g 4//6 Place of Disposition -gilt it.,) &Nilit
(address)
ILI
In
er (section) (p
�,��� (lot number) (grave number)
gName of Sexton or Person III Charge f Premises /ft.rtp�� hnt '
Z
lease print) .
I Signature aTitle CP t#194
•
(over)
DOH-1555 (02/2004)