Bogucki, William NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
William James Bogucki Male
Date of Death Age If Veteran of U.S. Armed Forces,
January 31, 2012 70 War or Dates
r Place of Death Hospital, Institution or
City, Town or Village Hudson Falls Street Address 19 Sue Lane
O Manner of Death 0 Natural Cause ElAccident ❑ Homicide 0 Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
Medical Certifier Name Title
Eric Pillemer, M.D
Address
100 Park Street Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City,Town or Village
0 Burial Date Cemetery or Crematory
February 10, 2012 Pine View
µ
❑Entombment Address
cq®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
':r❑ Removal and/or Held
and/or Address
Hold
Date Point of
A. ❑Transportation Shipment
VI by Common Destination
0 Carrier
Date Cemetery Address
III Disinterment
Date Cemetery Address
III Reinterment
Permit Issued to Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home 01078
Address
136 Main Street, South Glens Falls NY 12803
Name of Funeral Firm Making Disposition or to Whom
= Remains are Shipped, If Other than Above` e
Address
ti.. Permission is hereby granted to dispose of the human remains escribed above as indicated.
Registrarof Vital Statistics L-U
Date Issued a` "��,d�� _R
-_ (signature)
District Number S G(p Place 2 cst,sr, kc 1
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 02/10/2012 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) j (lot number) ( (grave number)
Name of Sexton or Per in Charg of Premises , )r,,sti fi4 r e f►rt '
4 . (please print)
Signature Title Coif V PTo(L
(over)
DOH-1555 (02/2004)