Polski, Doris A NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Doris A Polski Female
Date of Death Age If Veteran of U.S.Armed Forces,
11/09/2022 90 Years War or Dates
i-, Place of Death Hospital,Institution or
W City,Town or Village Glens Falls Street Address Glens Falls Hospital
p Manner of Death IJ Natural Cause Accident 0 Homicide Suicide riUndetermined riPending
W
U Circumstances Investigation
W Medical Certifier Name Title
0 Anthony Petracca MD
Address
3 Irongate Center,Glens Falls,New York 12801
Death Certificate Filed City Of Glens Falls District Number Register Number
City,Town or Village 5601 567
Burial Date Cemetery,Crematory or Facility Name
11/12/2022 Pineview Crematory
Entombment Address
▪Cremation Queensbury Town,New York
▪Donation
ZO❑Removal Date Place Removed
and/or and/or Held
I-
- Hold Address
0
d Date Point of
N❑Transportation Shipment
p by Common
Carrier Destination
Disinterment Date Cemetery Address
ElReinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Densmore Funeral Home Inc 00448
Address
7 Sherman Ave,Corinth,New York 12822
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped,If Other than Above
2 Address
CC
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11/10/2022 Registrar of Vital Statistics Megan Nolin(Electronically Signed)
(signature)
District Number 5601 Place City Of Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
IF-
WDate of Disposition )1117,1 lZ Place of Disposition , / -IL
2 (address)
W
NCC (section) /tot number) 306.4 (grave number)
0 Name of Sexton or Person in Charge of Prem. °' �"
Z ( e print)
W Title !k /1114 Ze
Signature
DOH-1555(07/18)p 1 of 2
I —_ „
Public Health Law Sec. 4145(2b)
1
1
Receipt
Human remains of delivered on .. , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#