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Pliscofsky Jr, Anthony NEW YORK STATE DEPARTMENT OF HEALTH th Vital Records Section Burial - Transit Permit Name First Middle Last Sex Anthony Pliscofsky Jr. Male Date of Death Age If Veteran of U.S. Armed Forces, February 21, 2015 61 War or Dates Place of Death Hospital, Institution or City, Town or Village Glens Falls Street Address Glens Falls Hospital Manner of Death El Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending Circumstances Investigation Medical Certifier Name Title Paul F. Bachman, Address 3767 Main Street Warrensburg, NY 12885 Death Certificate Filed District Number�Q� Register plumber City, Town or Village Glens Falls /00 ❑Burial Date Cemetery or Crematory e- February 23, 2015 Pine View Crematory ❑Entombment Address a -x®Cremation Quaker Road Queensbury,NY 12804 -.. Date Place Removed ❑ Removal and/or Held and/or Address h Hold Date Point of ❑Transportation Shipment by Common Destination Carrier ❑ Disinterment Date Cemetery Address ❑ Reinterment Date Cemetery Address rs Permit Issued to Registration Number Name of Funeral Home M. B. Kilmer Funeral Home- FE 01079 Address 82 Broadway, Fort Edward NY 12828 e .e& Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Address Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued Z.i 23 ) (5 Registrar of Vital Statistics �c,),Airi,..& V1_".. .t. Pr (sign ure) I 14 District Number �S6©/ Place G/E,S /c/�//.s / / i I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: ' Date of Disposition 02/23/2015 Place of Disposition Quaker Road Queensbury,NY 12804 (address) (lot number) (grave number) (section) /� ) Name of Sexton or Perso in C rge of Premises (please print) Signature Title GYwSP t� (over) DOH-1555 (02/2004)