Graska, Michael Al 713
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Michael L. Graska hl
« Date of Death Age If Veteran of U.S. Armed Forces,
04 / 17 / 2015 52 War or Dates
14 Place of Death Hospital, Institution or
fCity, Town or Village Greenfield Center Street Address 195 Bockes Road
a Manner of Death®Natural Cause 0 Accident 0 Homicide 0 Suicide 1-1
Undetermined ❑Pending
ILI Circumstances Investigation
ill Medical Certifier Name Title
44 Michael Sikirica MD
Address
50 Broad St., Waterford, NY 12188
kii Death Certificate Filed District Number Register Number
iMi City, Town or Village Greenfield Center 561
iiRii tJBurial Date Cemetery or Crematory Pine View Crematory
04 / 20 / 2015
':<``fEntombment Address
I Cremation 21 Quaker Road, Queensbury, NY
W Date Place Removed
Z❑Removal and/or Held
and/or Address
1,0
Hold
W. Date Point of
❑Transportation Shipment
' by Common Destination
IN Carrier
Disinterment Date Cemetery Address
. . Reinterment Date ' Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Compassionate Funeral Care, Inc 00364
;iii: Address
<: 402 Maple Ave., Saratoga Springs, NY 12866
Si Name of Funeral Firm Making Disposition or to Whom
in
Remains are Shipped, If Other than Above
2 Address
CC___,
Permission is hereby granted to dispose of the human remains described above as indicated.
ii Date Issued t/ao'vic Registrar of Vital Statist.
(signature)
Mi
District Number `4s1 Place Greenfield Center , - ew York
wi
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
La Date of Disposition Ifi za jc Place of Disposition Lalor;,....*
(address)
tl
N
I (section) lot number) (grave number)
ciName of Sexton or Person ip Charge of Premises ►a �14 '
Z e (ple e print)tE Signature Title e^hrr
(over)
DOH-1555 (02/2004)