Gazdik, Lawrence 1 Stge—
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
.:.• Name First Middle Last Sex
oc.: Lawrence E. Gazdik male
k,•.'•,: Date of Death Age If Veteran of U.S. Armed Forces,
i
01/21/201884 War or DatesAirforce
Place of Death
Hospital, Institution or
City, Town or Village Moreau Street Address Home of the Good Shepherd
Manner of Death x Natural Cause I I Accident Homicide Suicide Undetermined Pending
1g Circumstances Investigation
Medical Certifier Name Title
Christopher Hoy, MD
Address
rrr; 161 Carey Rd. Queensbury New York
h Death Certificate Filed District Number Register Number
',{: City, Town or Village Moreau [/S(o 2- 3
❑Burial Date Cemetery or Crematory
01/23/2018 Pine View Crematory
❑Entombment Address
Cremation Queensbury, NY
Date Place Removed
Z Removal and/or Held
and/or Address
t— Hold
N
O Date Point of
NI I Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
n Reinterment Date Cemetery Address
Permit Issued to Registration Number
;: Name of Funeral Home Regan and Denny Funeral Home 01444
:ti } Address
::4:
•:.;, 94 Saratoga Ave South Glens Falls, NY
r ; Name of Funeral Firm Making Disposition or to Whom
1'' Remains are Shipped, If Other than Above
Address
' :: Permission is hereby granted to dispose of the human remains described above as indicated.
.'�� Date Issued ,/231) g Registrar of Vital Statistics ./�
�:.::
(signature)
,-. District Number C f �j!,�/) Q'f 0120�
5 ie 3. Place ea 4,,
' I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition II Vi IIS Place of Disposition 9,1ck+., 6idr�,.,,
(address)
W
U)
tY (section) A (lot number (grave number)
Q Name of Sexton or Person in Charge of Pre ises [ha„ L. _ vvi4Itt
4
Zolease print)
W
Signature ' Title lrc'Klril L#
(over)
DOH-1555(02/2004)