Dommaschk, Andrew Walter 11l
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Andrew Walter Dommaschk Male
Date of Death Age If Veteran of U.S.Armed Forces,
05/14/2021 55 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
WW Manner of Death Undetermined Pending
El Natural Cause Accident Homicide Suicide
U Circumstances Investigation
W Medical Certifier Name Title
Melody Long PA
Address
100 Park Street,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 216
❑Burial Date Cemetery,Crematory or Facility Name
05/17/2021 Pine View Crematory
ElEntombment Address
O Cremation Queensbury Town,New York
Donation
g ❑Removal Date Place Removed
and/or and/or Held
Hold Address
0
IL 1-1
Date Point of
co Transportation
p by Common Shipment
Carrier Destination
Date Cemetery Address
❑Disinterment
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
F— Remains are Shipped,If Other than Above
Address
CC
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 05/17/2021 Registrar of Vital Statistics �o6ertf7nrrewCurtzr(ElectronualySWner9
(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:
W Date of Disposition -CIO 14 Place of Disposition rv.`L Z`�+�—
address)
W
CC CC (section) lotumber) (grave number)
A
Atitt
a Name of Sexton or Person in Charge of Pr ises P
Z C � (pleas riot) r P —0
W Signature //y// Title ` 'rl'�`
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) 014792
Receipt
Human remains of !delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#