Krulik, Ernest 1 *I in i
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Ernest F. Krulik Male
:r: Date of Death Age If Veteran of U.S. Armed Forces,
March 28, 2014 74 War or Dates
• Place of Death Hospital, Institution or
City, Town or Village Fort Edward Street Address Fort Hudson Nursing Home
gi Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certif'er Name Title
gl, (‘XV_XC\ene_ 1,1,0,:crircjvc, . A .
rj▪t.' ress
aj• 1 � lQddi.Jl)c i3 t Cor 4 wa` 1. t 1� laSag
Death Certificate Filed District Number Register Number
• City, Town or Village Fort Edward Fort Edward 6155 �,
❑Burial Date Cemetery or Crematory
March 31, 2014 Pine View Crematory
❑Entombment Address
❑x Cremation 51 Quaker Rd., Queensbury
Date Place Removed
Z Removal and/or Held
and/or Address
N Hold
U)
O Date Point of
Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
• 407 Bay Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
• Address
Jg
�: Permission is hereb granted to dispose of the human remains described above as indicated.
▪ Date Issued Registrar of Vital Statistics V Y
6-1 5 S (signature)
District Number F .Edward-PFace Fort Edward
I certify that the remains of the decedentidentified above were disposed of in accordance with this permit on:
W Date of Disposition / 7 Place of Disposition /?,iL v i5,ti (2,witiii-Aiv
2 (address)
W
N
CC
(section) t num er) / (grave number)
pName of Sexton o e rge of Premises �� g(k)cnt)t CY
W (please print) �/�
Signature 444. -- Title � ,� %TS -
(over)
DOH-1555(02/2004)