Zegarski, Mildred 41
NEW YORK STATE DEPARTMENT OF HEAL1`H L 7Z I
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Mildred Zegarski Female
iii Date of Death Age If Veteran of U.S. Armed Forces,
90 rs. War or Dates no
Place o�eth3 0, 2013 y Hospital, Institution or
City, Town or Village Fort Ann Street Address 11 Atkinson Lane
I Manner of Death x❑ Natural Cause ❑Accident ❑Homicide I__I Suicide ri Undetermined ri❑Pending
Circumstances Investigation
Medical Certifier Name Title
1 James Hicks, MD.
Address
Healthcare on Broad St. , Glens falls, NY. 12801-
Death Certificate Filed District Number Register NAnber
City, Town or Village Fort Ann 5754 /
Date Cemetery or Crematory
❑Burial Dec. 02, 2013 PineView Crematorium
Address
�remation Quaker Rd. , Queensbury, NY. 12804
Date Place Removed
0 I—I❑Removal and/or Held
and/or Address
Hold
Date Point of
y ❑Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
<: Permit Issued to Registration Number
<= Name of Funeral Home Mason Funeral Home 01117
Address
in 18 George St. , Fort Ann, NY. 12827
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
FL
i`'3 Permission is hereby granted to dispose of the human re ins described above indic ted.
>< Date Issued 1 1 /3 0/1 3 Registrar of Vital Statistics z- ren,....L.19
(sign re)
Mi
<` District Number 5754 Place Town of Fort Ann, NY.
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
f-
WDate of Disposition i2-3-1 Place of Disposition ."Ok,.0 C, ,.ctar,_
2 (address)
iu
N
CC (section) (lot umb r) (grave number)
Name of Sexton or Perso in Charge of PremisesCi n.) ,.- 3' .!ti-
g (please print) Ir
4J Signature IL IL-- Title Ct w►p '
(over)
DOH-1555 (9/98)