Kulawy, Andrew Steven Jno
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Andrew Steven Kulawy Male
Date of Death Age If Veteran of U.S.Armed Forces,
06/20/2021 75 Years War or Dates
Place of Death Hospital,Institution or
WCity,Town or Village Queensbury Town Street Address 26 Willow Road,Queensbury Town, New York 12804
0 Manner of Death R Natural Cause ❑Accident ❑ Homicide Suicide ❑Undetermined ❑Pending
Circumstances Investigation
Medical Certifier Name Title
CI Charles Yun MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Queensbury 5657 130
❑Burial „ Date Cemetery,Crematory or Facility Name
06/23/2021 Pine View Crematory
LLJ Entombment Address
gCremation Queensbury Town,New York
Donation
ElRemoval Date Place Removed
and/or and/or Held
Hold Address
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p by Common Shipment
Carrier Destination
IDDisinterment 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
i... Remains are Shipped,If Other than Above
2 Address
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a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 06/23/2021 Registrar of Vital Statistics Caroline Niffegarde Barb-er(Ekctronica1'Signed)
(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:
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