Helenek, Irene C NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Irene C.Helenek Female
Date of Death Age If Veteran of U.S.Armed Forces,
01/13/2023 90 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Wilton Town Street Address 60 Waller Road,Wilton Town, New York 12831
W Manner of Death nUndetermined Pending
W Z Natural Cause Accident �Homicide nSuicide I I
Circumstances Investigation
WMedical Certifier Name Title
Madison Zuis NP
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed Town Of Wilton District Number Register Number
City,Town or Village 4569 3
Burial Date Cemetery,Crematory or Facility Name
01/13/2023 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
Z❑Removal Date Place Removed
and/or and/or Held
H Hold Address
O
G. Date Point of
U)ElTransportation
Q by Common Shipment
Carrier Destination
Date Cemetery Address
Disinterment
Date Cemetery Address
Reinterment
Permit Issued to Registration Number
Name of Funeral Home Brewer Funeral Home Inc 00211
Address
24 Church Street PO Box 500,Lake Luzerne,New York 12846
Name of Funeral Firm Making Disposition or to Whom
F— 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 01/13/2023 Registrar of Vital Statistics Susan Baldwin(Electronically Signed)
(signature)
District Number 4569 Place Town Of Wilton
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
~ l
Z Date of Disposition /—/��ZOL 3 Place of Disposition ;�e Cr14-44,
W
2 (address)
W
NCC (section) (lot num e)r (grave number)
Name of Sexton or Person in Charge of Premises �(j v
(p ease print)
lL Signature Title
`C/G�
DOH-1555(07/18)plot 2 —
\!
016594
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#