Kolakowski, Edmund F NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Edmund F.Kolakowski Male
Date of Death Age If Veteran of U.S.Armed Forces,
01/26/2023 94 Years War or Dates 1952-1954
Place of Death Hospital,Institution or
WCity,Town or Village Horicon Town Street Address 7303 State Route 8,Horicon Town,New York 12815
`p Manner of Death ElNatural Cause ❑Accident El Homicide Suicide Undetermined Pending
V Circumstances Investigation
C Medical Certifier Name Title
Paul Bachman MD
Address
9 Carey Rd,Queensbury Town,New York 12804
Death Certificate Filed Town Of Horicon District Number Register Number
City,Town or Village 5654 01
Burial Date Cemetery,Crematory or Facility Name
01/27/2023 Pine View Crematorium
Entombment Address
['Cremation Queensbury Town,New York
DDonation
OZ❑Removal Date Place Removed
and/or and/or Held
N Hold Address
0
a Date Point of
to❑Transportation
ES Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
Reinterment 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
E— Remains are Shipped,If Other than Above
a Address
W
t1 Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/27/2023 Registrar of Vital Statistics Krista£Wood(E(ectronicaQySigned)
(signature)
District Number 5654 Place Town Of Horicon
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 11111 11,3 Place of Disposition -(I oc/k 6¢c ini\-11Y41
2 (address)
W
CC (section) ,(lot numb (grave number)
ttName of Sexton or Person in a of Premises G n Ll- �'^�
Z please print)
W Signature Title ����
DOH-1555(07/18)p t of 2
6 6
Public Health Law Sec. 4145(2b) ' `'
Receipt
Human remains of -= delivered on , 20
Pine View Cemetery Representing the funeral home named oil burial permit
Official Funeral Directors Reg.or License#