Kowalski, Jr. Louis 03/27/2018 04:20PM 17162844660 Zajac FH Inc. PAGE 05/05
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NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
F Name First Middle Last Sex .
3,., Male
�, . Louis Kowalski Jr. •
Date of •• =th Age If Veteran of U.S.Armed Forces, • .
•,5 03/28/2016 86 Years War or:Dates 1949-1962
Place of •eath Hospital, Institution or
a City, Town•or Village Queensbury rows Street Address Warren Center for Rehabilitation and.Nursing
Mother of Death a Natural Cause E]Accident [�Homicide [,�Suicide Undetermined Pending.
' Circumstances •Investigation .
7i Medical Certifier Name . Title
r•:t Roslyn Socolof • MD • •
r"s� • Address .
•
,' ..
42.gurney ln,Queensbury Town,New York 12804 '
• h Certificate filed District'Number Register Number .
4 C Town.or Village• Queensbury ,''- 5657 • 44 •
i` DBUrial . •' • Date . . Cemetery or Crematory - '
n`.. 03t28/2018 • Pineview Crematory.
;; EntombmentD Address • _
,gip;®Cremation Queensbury Town, New York'• .
' ` • Date Place Removed
7 Removal . 1 and/or Held •
° and/or
r; Hold
Address
`T Date Point of •
Transportation Shipment
by Common Destination •
s Carrier
Date Cemetery Address •
Disinterment
0 Reinterment Date Cemetery Address •
' Permit Issued to Registration Number •
al
Name of Funeral Home Zajac Funeral Home Inc 01855
pll Address
-,1,] 319 24th St,Niagara•Falls,New York 14303 .
' ': Name of Funeral Firm Making Disposition or to Whom
Remains are Ship.ed, If Other than Above .
Address
Permission is hereby granted to dispose of the human remains described above as indicated. .
Date Issued 03/27/2018 Registrar of Vital Statistics Ceram MOmftrr(tEfectmntceiIySigned)
. . (signature)
iii,1District Number 5657 Place Queensbury, New York •
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition• -d,q_.i Y Place of Disposition p;At, V,c,v C.fewlu ,r r X .
,�j (ad 'dress) •
(aeaion) (lot number) : •(grave number)
'' • Name of Sexton or Person in Charge of Premises 1 .0 A^s Y .,SZ\,ti`rvS
M. (vreeee me* •
F'F: Signature •leTitle C.itrIcrior
• (over)
•
DOH-1555(02/2004)