Zwijacz, Madeline Marie k IZL
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NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
;- Name First Middle Last Sex
, Madeline Marie Zwijacz Female
-' Date of Death Age If Veteran of U.S. Armed Forces,
, 1/31/2021 Stillborn War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death ❑X Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined n Pending
Circumstances Investigation
Medical Certifier Name Title
K/1Tk '1.) Ci-Of M.p
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Death Certificate Filed D strict Number Register Number
City, Town or Village Glens Falls,NY 5601
❑Burial Date Cemetery or Crematory
February 3,2021 Pine View Crematorium
❑Entombment Address
®Cremation 51 Quaker Road,Queensbury, NY 12804
Date Place Removed
z ❑Removal and/or Held
and/or Address
H Hold
QDate Point of
y ❑Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
l% Permit Issued to Registration Number
,
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Wil Address
407 Bay Road,Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
s
1
Permission is h re y granted to dispose of the human remains escribed above as indicated.
Date Issued a a a Registrar of Vital Statistics
LhLiitt4Coz-d
(signet
District Number Place G ( 5 l 5, N
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I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 219 (Z' Place of Disposition (L 40,„_....
2 (address)
W
CO
I Z (section) 4(lot number) (grave number)
pName of Sexton or Person in C arge of Premises /11(i (1L, ,)v►4'l7
Z (ple a print)
W -...;
Signature ��^^� Title /11VCA KIK
(over)
DOH-1555(02/2004)
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Public Health Law Sec. 4145(2b) 01
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#