Krihak, Paul NEW YORK STATE DEPARTMENT OF HEALTH '
Vital Records Section Burial - Transit Permit
F Name First Middle Last Sex
M Paul Roland Krihak Male
r.P. Date of Death Age If Veteran of U.S. Armed Forces,
15,June 2014,.�� 90 War or Dates World War II
k'''' Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address 20 Elm Street,Apartment 503
Manner of Deathu_ik Natural Cause ri Accident 0 Homicide n Suicide n Undetermined n Pending
Circumstances Investigation
Medical Certifier Name Title
Glen Anderson,PA
'.'>'._ Address
161 Carey Road,Queensbury,NY 12804
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls,NY 5601 2 ' 2,
0 Burial Date Cemetery or Crematory
June 17,2014 Pine View Crematorium
❑Entombment Address
0 Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z ri Removal and/or Held
and/or Address
E Hold
CO
O Date Point of
N E Transportation Shipment
p by Common Destination
Carrier
n Disinterment Date Cemetery Address
Ei
Reinterment Date Cemetery Address
s- Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
t'`F Address
407 Bay Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
44-
y Permission is hereby granted to dispose of the human remains described above as indicated.
r
Date Issued (:)I i —1 I (Z Registrar of Vital Statistics cW�
l�'y (sign ture)
` District Number 5601 Place Glens Falls,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z y�,
ILI Date of Disposition 6 fight' Place of Disposition / "' C 4prt,,,,
2 (address)
Cl)
0 (section) `1 ,(lot number) (grave number)
p Name of Sexton or Person in Char a of Premises G r+� �
W d lease print)Signature — Title Ct arl
v (over)
DOH-1555(02/2004)