Krzys, Barbara NEW YORK STATE DEPARTMENT OF HEALT 1 . '*y if 10
Vital Records Section Burial - Transit Perm t
Name First Middle Last Sex
Barbara E. Krzys Female
Date of Death Age If Veteran of U.S. Armed Forces,
9 a 201 8 89 yrs War or Dates no
Place of Death ,� Hospital, Institution or
Z City, Town or Village Fort Ann Street Address 1 1 81 CopelandPond Rd.
IliManner of Death®Natural Cause 0 Accident El Homicide 0 Suicide riUndetermined D Pending
'ti Circumstances Investigation
tu Medical Certifier Name Title
0 Kristenrq Kelley DO.
Grdeenwich Family Health
Greenwich, NY.
Death Certificate Filed District Number Register Number
City, Town or Village Fort Ann 5754 1 2
❑Burial Date Cemetery or Crematory
Nov. 09, 2018 PineView Crematorium
Li Entombment Address
1Cremation Queensbury, NY. 1 2 04
Date Place Removed
Z n Removal and/or Held
' 3 and/or
Address
F= Hold
#a
Date Point of
Q ri 0Transportation Shipment
O by Common Destination
Carrier
ii ❑Disinterment Date Cemetery Address
Ail ElReinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Mason Funeral Home 01 1 1 7
Address
18 George St. , PO. Box 277, Fort Ann, NY. 12827
Name of Funeral Firm Making Disposition or to Whom
i- Remains are Shipped, If Other than Above
• Address
C
Ill
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 1 1 /0 9/1 8 Registrar of Vital Statistics '/�� 4:1
(signature)
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:
i
Ili• Date of Disposition 4 /13 Iv‘ Place of Disposition fi.Li 6,/16,a (addres
Lu
CC (section) tigrt member) (grave number)
14▪ Name of Sexton or Person in Charge of P'emisest'r 44
��
(pleas print) �t�
Signature
Title 0 t 1�'
(over)
DOH-1555 (02/2004)