Kantorski, Wayne NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Wayne Kantorski Male
, Date of Death Age If Veteran of U.S. Armed Forces,
t I- 06/13/2018 64 Years War or Dates
ti
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
• Manner of Death 0 Natural Cause 0 Accident n Homicide 0 Suicide ri❑Undetermined �Pending
Circumstances Investigation
trl
Medical Certifier Name Title
Jean Vanauken PA
Address
100 Park St,Glens Falls,New York 12801
i . Death Certificate Filed District Number Register Number
.- City, Town or Village Glens Falls 5601 303
0Burial . Date Cemetery or Crematory
06/18/2018 Pine View Crematory
- Entombment Address
®Cremation Queensbury Town, New York
Date Place Removed
❑Removal and/or Held
_: and/or
Address
Hold
-77
Date Point of
0 Transportation Shipment
✓ by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D Baker Funeral Home 01130
c4 Address
11 Lafayette St,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
a• Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 06/18/2018 Registrar of Vital Statistics Robert Curtis(ECectronicaffy Signed)
(signature)
11
-- District Number 5601 Place Glens Falls, New York
, I certify that the remains of the decedent identified above were disposed of in accordanceJ with this permit on:
Date of Disposition 41rt I I$ Place of Disposition L -1 (n.-0•--
(address)
(section) (lot mber) (grave number)
(Lit ' 5...
Name of Sexton or Person in Charge of Premises N'�p
(please/print)
Signature [� Title thfMI IDA2
(over)
DOH-1555 (02/2004)