Kosciukiewicz, Bernice NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Bernice Kosciukiewicz Female
Date of Death Age If Veteran of U.S.Armed Forces,
09/04/2021 89 Years War or Dates
1.. Place of Death Hospital,Institution or
WCity,Town or Village Johnsburg Town Street Address Elderwood at North Creek
pManner of Death El Natural Cause 0 Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
V Medical Certifier Name Title
G Michael Miles MD
Address
112 Ski Bowl Rd,Johnsburg Town,New York 12853
Death Certificate Filed District Number Register Number
City,Town or Village North Creek 5655 34
ElBurial Date Cemetery,Crematory or Facility Name
09/07/2021 Pine View Crematorium
El Entombment Address
0 Cremation Queensbury Hamlet,New York
ElDonation
Removal Date Place Removed
and/or and/or Held
H Hold Address
CO
0
O. ❑ Date Point of
f/) Transportation
a by Common Shipment
Carrier Destination
ElDisinterment Date Cemetery Address
ElReinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Barton-Mcdermott Funeral Home Inc 00141
Address
9 Pine St,Chestertown,New York 12817
Name of Funeral Firm Making Disposition or to Whom
i.. Remains are Shipped,If Other than Above
2 Address
Q
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 09/07/2021 Registrar of Vital Statistics 7(¢tfcleen C.Lorafi(Efectmnica1TySigned)
(signature)
District Number 5655 Place North Creek, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition R` 1 N Place of Disposition Rif L 4�_
iti
2 (address
W
CA
CC (section) Aofp
(lot number) (grave number)
2 Name of Sexton or Person in Charge f remises ? e lease
,44-
Z /� lease print/ /�
W Signature / Title ilk,km r
DOH-1555(07/18)p 1 of 2
0 1 5120
Public Health Law Sec. 4145(2b)
Receipt
_h` d
Human remains of P'' delivered on , 20
Pine View Cemetery Representing the funeral home named,on burial permit
Official Funeral Directors Reg.or License#