Walczak, Edward « _ J .7
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Edwa4d Walczak Male
Date of Death Age If Veteran of U.S. Armed Forces,
12 / 02 / 2015 79 War or Dates
1 Place of Death Hospital, Institution or Saratoga Hospital
ZCity, Town or Village Saratoga Springs Street Address
is Manner of Death®Natural Cause 0 Accident Homicide 0 Suicide Undetermined �Pending
f Circumstances Investigation
• Medical Certifier Name Title
O Desmond Del Giacco MD
Address
59 Myrtle St # 300, Saratoga Springs, NY 12866
Death Certificate Filed District Number Register Number
City, Town or Village Saratoga Springs
#nBurial Date Cemetery or Crematory
12 / 04 / 2015 Pine View Crematory
Entombment Address
Cremation 21 Quaker Road, Queensbury, NY 12804
Date Place Removed
Z❑Removal and/or Held
Q and/or Address
f= Hold
410
{ Date Point of
ick Q Transportation Shipment
5 by Common Destination
Carrier
giiiiiEl Disinterment Date Cemetery Address
Q Renterment Date Cemetery Address
M.: Permit Issued to Registration Number
Name of Funeral Home Compassionate Funeral Care, Inc 00364
Address
Ill 402 Maple Ave., Saratoga Springs, NY 12866
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
• Address
lI
:>R` Permission is hereby granted to dispose of the human remapcie ri d abop ' dicate
Mi
Date Issued j9. f)91)tç Registrar of Vital Statistics
(signature)
`« District Number - rt y)) Place Saratoga Springs , New York
': I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ill Date of Disposition f .7_/S' Place of Disposition ri'na,,,'E>w C1'42r,,s'1er�'.jn
(address)
Ul
IX (section / (lot number) (grave number)
aName of Sexton or Person inCharge of Premises - .�tiy .�rurlo/%P
z (please print) .
tEt Signature 4,4.- �,�, Title Creh,a Mcs�
(over)
DOH-1555 (02/2004)