Lizewskie, Marcelline E NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Marcelline E.Lizewskie Female
Date of Death Age If Veteran of U.S.Armed Forces,
06/10/2022 84 Years War or Dates
F— Place of Death Hospital,Institution or
Z City,Town or Village Plattsburgh Street Address Champlain Valley Physicians Hospital Medical Ctr
Mannerof Death a Natural Cause Accident El Homicide Duicide Undetermined Pending
W 0 Circumstances Investigation
W Medical Certifier Name Title
C George Ciolac MD
Address
75 Beekman St,Plattsburgh,New York 12901
Death Certificate Filed city Of Plattsburgh District Number Register Number
50901 Cit ,Town or Village
299
X Burial Date Cemetery,Crematory or Facility Name
06/14/2022 Pine View Cemetery
Entombment Address
❑Cremation Queensbury Town,New York
Don atio n
Z Removal Date Place Removed
and/or and/or Held
NHold Address
0
a Date Point of
C)❑Transportation Shipment
p by Common
Carrier Destination
'Disinterment
Date Cemetery Address
Date Cemetery Address
El Reinterment
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
F— Remains are Shipped,If Other than Above
2 Address
cc
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 06/13/2022 Registrar of Vital Statistics Sylra yailPanvtte(*Electmnica8'5 'ned)
(signature)
District Number 0901 Place City Of Plattsburgh
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
f
W Date of Disposition L. y.�1 Place of Disposition (`)1 C)K ,Q RD �A)t)e cc i - J )�(�!
(address/ l
W S , � if 11
co (semi (lot number/ (grave number)
2 Name of Sexton or Person in C,}arge'ef+Premis s /-10l e ` S 2QC 2J—
Z (please print'
W Signature i 64/ Title (7!/`x ri0 YiC/I f"
r
DOH 1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b)
012924
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#
LIZEWSKIE
NAME Marcelline E.Lizewskie Age: 84
Lot Owner: Henry Lizewskie
Lot# S&I #2 1 1 5 Grave# 2
Case: Concrete
Died: 6. 1 0.2 2 Interred:6. 1 4.2 2
Funeral Home: Regan Denny Stafford
Cemetery: Pine VIew
Lizewsi ie
Lot No. 115
Address Roberts Gardens Arts. Bldg. 35 Apt. 3 Glens Falls, N.Y. 12801 Section No. 2
Owner Henry Lizewskie Plot S.I.
Date 5/99/86
Approx. 67 Superficial ft. @
Location Bounded North by Timms,_ South by Blanchard & Ra1l, Past by Hayes, West by Carpenter
Corner Posts
Remarks
Deed No. (and changes) 1996
Payment Record paid in Fill 5/29/86
Record of Interments „ f uM v5 /rrrL'6,E
i Henry Lizewskie 2/3/90
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Form No. 01