Mrozinski, Mary ICO
NEW YORK STATE DEPARTMENT OF HEALTH + - .w
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
rr: Mary A. Mrozinski Female
;;1 Date of Death Age If Veteran of U.S. Armed Forces,
i$i: September 26,2015 87 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Queensbury Street Address 2 Wincrest Drive
12 Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
. Robert Love,MD
f Address
j:; Three Irongate,Glens Falls,NY
r Deat cate Filed District Number Register Number
;;;1 City own o Village g k.��, .r -(05-1 i.5�
❑Burial Date Cemetery or Crematory
September 29, 2015 Pine View Crematory
❑Entombment Address
❑X Cremation Quaker Road, Glens Falls, NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
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0 Date Point of
Nn Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
;r'; Name of Funeral Home Regan Denny Stafford Funeral Home 01443
:i Address
53 Quaker Road, Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
' Remains are Shipped, If Other than Above; e
r Address
f Permission is hereby granted to dispose of the human ma debsc '2 : , • <ve as ' icated.
{ll: ``
.;,� Date Issued ��i'�Registrar of Vital St 'stics � (4.
District Number 5t151 Place !/1/D(
,::::::
I certify that the remains of the decedent identified ab a were dis sed of in ac rdance with this permit on:
Z
W Date of Disposition %o/z(ls Place of Dispositio ,_.. C 6rW,_
W address)
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0 (section) (lot number) 0 (grave number)
p Name of Sexton or Person in Charge of Premises thr,; 1,.. Je.wl#f
Z (pl se print)
W l
Signature !P Title (11601 OIC
(over)
DOH-1555(02/2004)