Hubicki, Hazel NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Hazel Viola HUBICKI M
Date of Death Age If Veteran of U.S. Armed Forces,
1 2/8/9 8 8 2 War or Dates
Place of Deat Hospital, Institution or
City, Town or TOGA SPRINGS Street Address 13 MIchael Dr
Manner of Death FX�Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined El Pending
Circumstances Investigation
Medical Certifier Name Title
John Koella MD
Address
414 Maple ave Saratoga Springs, NY 12866
Death Certificate Filed District Nu Regis er Number
City, Town or Village
Date . Cemetery or Crematory
❑Burial 1 2/1 0/98 Pineview Crematory
Address
®Cremation Quaker Rd Queensbury, NY 12804
FDate Place Removed
Z❑Removal and/or Held
... and/or Address
Hold
Q Date Point of
N ❑Transportation Shipment
by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Tunison Funeral Home 01 898
Address
105 Lake Ave Saratoga Springs, NY 12866
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remain scri d above a icated.
Date Issued 12/0/9 8 Registrar of Vital Statistics
(sig
District Number
Place S, TORAH SPRINGS
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
,(�
DW. ate of flisposition/ Place of Disposition �4ly7
W (address)
iu
x (section) (lot number) , / (grave number)
GName of Sexto or Perso in Charge of Premises . �lcJ�/ �f %� �✓
(please print)
W Signature Title
DOH-1555 (10/89) p. 1 of 2 VS-61