Rojcewicz, Mary NEW YORK STATE DEPARTMENT OF HEALTH t I I/ Sor
Vital Records Section Burial - Transit Permit
,4- Name First Middle Last Sex
Mary I. Rojcewicz Female
Date of Death Age If Veteran of U.S. Armed Forces,
August 1, 2014 96 War or Dates
• Place of Death Hospital, Institution or
, City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death X❑ Natural Cause El Accident El Homicide El Suicide ❑ Undetermined � Pending
Circumstances Investigation
Medical Certifier Name Title
Michael Adams, Dr.
tkt
Address
10154 Saratoga Raod Fort Edward, NY 12828
Death Certificate Filed District Number Register mb r
,, , G
Ci Town or Villa a Glens Falls �C
• 0 Burial Date Cemetery or Crematory
14 Pine View Crematory
0 Entombment
, Address
®Cremation Quaker Road Queensbury,NY 12804
Removal Date Place Removed
and/or and/or Held
• Hold Address
Date Point of
'❑Transportation Shipment
by Common Destination
` Carrier
riii ❑ Disinterment Date Cemetery Address
it
x 0 Reinterment Date Cemetery Address
• Permit Issued to Registration Number
Name of Funeral Home M. B. Kilmer Funeral Home 01079
V• Address
82 Broadway, Fort Edward NY 12828
,; Name of Funeral Firm Making Disposition or to Whom
v Remains are Shipped, If Other than Above
Address
_x
Permission is her by granted to dispose of the human r.mains • cribed abo e as ' ica ed.
Registrar of Vital Statistics r
Date Issued g L -
(signature)
District Number c5 O/ Place bit' s ,/li Al/ / -8j
• I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition (aril it Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) /jot number) (grave number)
.. Name of Sexton or Person in Charge of remises awl... Se1 JD
(pledse print)
« Signature G��. Title P 'I/�4C
(over)
DOH-1555 (02/2004)