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Jankowsky, Frank E. NEW YORKSTATE DEPARTMENT OF HEALTH Bureau of Vital Records Burial - Transit Permit Name First Middle Last Sex Frank E Jankowsky Male Date of Death Age If Veteran of U.S.Armed Forces, 01/17/2021 99 Years War or Dates F. Place of Death Hospital,Institution or W City,Town or Village Glens Falls Street Address Glens Falls Hospital p Manner of Death ©Natural Cause Accident Homicide ❑Suicide Undetermined ❑Pending IJJ C.) Circumstances Investigation UJ Medical Certifier Name Title CI Michael Miles MD Address 100 Park St,Glens Falls, New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Glens Falls 5601 37 ©Burial Date Cemetery,Crematory or Facility Name 01/22/2021 Pine View Cemetery Entombment Address ElCremation Queensbury Town,New York ❑Donation 0 Removal Date Place Removed and/or and/or Held pN Hold Address Vl L j Transportation Date Point of p by Common Shipment Carrier Destination rjDisinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Regan Denny Stafford Funeral Home 01443 Address 53 Quaker Rd,Queensbury, New York 12804 Name of Funeral Firm Making Disposition or to Whom 1— Remains are Shipped,If Other than Above 2 Address W O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 01/20/2021 Registrar of Vital Statistics W96ert Andrew Curtis(E(ectronica1TySigned) (signature) District Number 5601 Place Glens Falls, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: I- W Date of Disposition 1 /2 2/2 0 21 Place of Disposition 21 Quaker RD Queensbury, Ny 1 280 4 2 (address) W Horicon 4E 1 N CC (section) (lot number) (grave number) 0 Name of Sexton• I erson in Charge of Premises Connie Goedert Z (please print) W Signature , P "Lei - .P Title Superintendent DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) 1 012838 Receipt Human remains of I- • delivered on , 20 t v,.� Piro"a View Cemetery ` Representing the funeral home named on burial permit Official Funeral Directors Reg.or License# Jankowsky I@ NAME Frank E. Jankowski Age: 99 Lot Owner: Frank E. Jankowsky Lot# Grave# Horicon 4E 1 Case: Concrete Died: 1 /1 7/2 0 21 Interreda /2 2/2 0 21 Funeral Home: Regan Denny Stafford FH Cemetery: pine View