Malecki, Stanley Walter NEW YORKSTATE DEPARTMENT OF HEALTH e -- �11
Bureau of Vital Records Burial - Transit Permit
Name First Middle Last Sex
Stanley Walter Malecki Male
Date of Death Age If Veteran of U.S.Armed Forces,
12/03/2020 79 Years War or Dates
F,. Place of Death Hospital,Institution or
WCity,Town or Village Queensbury Town Street Address Warren Center for Rehabilitation and Nursing
p Manner of Death Le Natural Cause El Accident El Homicide ID Suicide Ei Undetermined El Pending
W C.) Circumstances Investigation
G Medical Certifier Name Title
Roslyn Socolof MD
Address
42 Gurney Ln,Queensbury Town,New York 12804
Death Certificate Filed District Number Register Number
City,Town or Village Queensbury 5657 216
ElBurial Date Cemetery,Crematory or Facility Name
12/04/2020 Pine View Crematory
- ElEntombment Address
ElCremation Queensbury Town,New York
❑Donation
O• ElRemoval Date Place Removed
H and/or and/or Held
N Hold Address
0
Q. Date Point of
N ❑Transportation
CI Common Shipment
Carrier Destination
Disinterment
Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D Baker Funeral Home 01130
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
CC
n' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/03/2020 Registrar of Vital Statistics Carotinex[gard Barger glectronical5'Sgned)
(signature)
District 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:
W Date of Disposition �, -,j-.7p2p Place of Disposition -Je e„t) L't-
2 (address)
W
fA
CC (section) (lot number)1 (grave number)
• Name of Sexton or Person in Ch ge of Prem. (-?(a�fYlfe+'� �� l(1D
Z (please print)
W Signature f6 /44 Title
DOH 1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) f 1 112 6 6
Receipt
Human remains of delivered on - • , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License# `.