Kaczorowski, Theresa 0 �i
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First
�,r� Middle Last Sex
�:;. Theresa J. Kaczorowski Female
r : Date of Death Age If Veteran of U.S. Armed Forces,
August 6, 2014 95 War or Dates
4rti Place of Death0
Hospital, Institution or
City, Town or Village Street Address Washington Center
gi Manner of Death I XI Natural Cause I I Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Edit K.Masaba
'▪ ' Address
: 135 Gilbert St, Cambridge,NY 12816
:�: Death Certificate Filed District Number Register Number
4 j City, Town or Village Argyle 3150 30
❑Burial Date Cemetery or Crematory
❑Entombment August 8, 2014 Pine View Crematorium
Address
❑x Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z
Removal and/or Held
and/or Address
r' Hold
CO
O Date Point of
NTransportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
n Renterment Date Cemetery Address
:§: Permit Issued to Registration Number
::'.. Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
ti.: Address
407 Bay Road, Queensbury, NY 12804
'▪ ' 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 hu ains described above a in icated.
i c1
r: ' Date Issued 5- 5- LA4� Registrar of Vital Statistics \ Q3,g��1�1 �j 11,6 UJ �
`� (signature)
:i District Number 5150 Place Argyle
I certify that the remains of the decedent identified above were disposed of in accordanceac with this permit on:
W IN of Disposition Sit� Place of Disposition dfj CC,..rrdr.....
Ill
(address)
CO
CL (section) (lot num ) (grave number)
pName of Sexton or Person in Charge of PremisesA*1 Mr+Gt
Z lease print)
Wit Signature 3-_► Title C12-ternA fri•
(over)
DOH-1555(02/2004)