Watulak Sr, William NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
William J. Watulak Sr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
11/28/2015 91 years War or Dates WWII
f- Place of Death Hospital, Institution or
Z City, T Street Address
Ili °X`' ' �X Saratoga S rings Sarato a H s ital
W Manner of Death❑Natural Cause Li Accident ❑Homicide ❑Suicide ?unc?etermined ❑Pending
Circumstances Investigation
W Medical Certifier Name Title
a nr. Heather Madigan D. O.
Address
211 Church Street, Saratoga Springs, Ny
Death Certificate Filed District Number Register Number
City, Toxxixx V jteVX Saratoga Springs 4S01 565
' ['Burial Date Cemetery or Crematory
❑Entombment 12/03/2015 Pine View Crematory
Address
[,]Cremation Queensbury, N Y
Date Place Removed
Z ❑Removal and/or Held
2 and/or Address�
Hold
to
0 Date Point of
CL
co ❑Transportation Shipment
a by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Densmore Funeral Home 00448
Address
7 Sherman Ave, Corinth, New York 12822
Name of Funeral Firm Making Disposition or to Whom
Ir. Remains are Shipped, If Other than Above
Z Address
is
tii
�' Permission is hereby granted to dispose of the human remai cri ed ab e as indicated.
Date Issued 11/30/2015 Registrar of Vital Statistics r- qt/uvAcik
(signature)
District Number 4501 Place Saratoga Springs
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
Ul Date of Disposition ! a-L/- 15 Place of Disposition ne tJ,}P(✓ CreM col or.'L9 :n
2 (address)
1J.1
N
CC (ser (lot number) (grave number)
aName of Sexton or Person in Ch ge of Premises (i rh 04-h y e/1'C
Z ( (please print)
W Signature d.t^N14 Title Cre01 a-kav i AsS4
(over)
DOH-1555 (02/2004)