Grodnick, Katherine NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name / First Mid le ast Se
r Ira" �-
Date of Death Age If Veteran of U.S. Armed Forces,
3/1 7/9 8 53 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Saratoga Springs Street Address Saratoga Springs, NY
Manner of Death❑Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
Medical Certifier Name Title
H. Fletcher Starnes MD
Addrels North Van DAm ST Saratoga Springs, NY 12866
Death Certificate Filed District Number Regist r Number
. City, Town or Village Saratoga Springs 4501
Date Cemetery or Crematory
❑Burial March 18, 1998 Pineview Crematory
Address
®Cremation Quaker Rd Queensbury, NY 12804
Date Place Removed
z❑Removal and/or Held
••.. and/or Address
Hold
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 FrH 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 rema' s d c ed a v a ed.
Date Issued 3/1 8/9 8 Registrar of Vital Statistics -
(signature)
» District Number 4501 Place Public Safety, Saratoga Springs, NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W. Date of Disposition Place of Disposition
W (address)
w
VJ
section) (lot numbe ) , / (grave number)
GName of Sexto or Person in Charge of Premises
0 (please print) T
Signature Title r
DOH-1555 (10/89) p. 1 of 2 VS-61