Wachowski, Frederick NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Frederick Wachowski Male
Date of Death Age If Veteran of U.S.Armed Forces,
11/26/2023 57 Years War or Dates
1• Place of Death Hospital,Institution or
WCity,Town or Village North Hudson Town Street Address 170 Pepper Hollow Road,North Hudson Town,New York 12855
p Manner of Death []Natural Cause []Accident []Homicide Suicide Undetermined Pending
U1 1 Circumstances IlInvestigation
CI
Medical Certifier Name Title
Kellie Valentine Coroner
Address
PO Box 132,Elizabethtown Town,New York 12932
Death Certificate Filed Town Of North Hudson District Number Register Number
City,Town or Village 1561 03-23
Burial Date Cemetery,Crematory or Facility Name
11/30/2023 Pine View Crematory
Entombment Address
[]Cremation Queensbury Town,New York
Donation
ZZ Removal Date Place Removed
and/or and/or Held
H Hold Address
0
IlL Date Point of
(I)❑Transportation
by Common Shipment
Carrier Destination
[]Disinterment Date Cemetery Address
[]Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Edward L Kelly Funeral Home 00519
Address
PO Box 548,Schroon Lake,New York 12870
Name of Funeral Firm Making Disposition or to Whom
1— 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 11/29/2023 Registrar of Vital Statistics Martlra ft ing(Electronica4 Signed)
(signature)
District Number 1561 Place Town Of North Hudson
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition 121 1 23 Place of Disposition �Td E'E J (Pe Alf 'ti/itv`
(address)
W
CC
CC (section) pot number (grave number)
Name of Sexton or Person in Charge of Pre .ses P"AL-- t M
111
lease print)Signature _ Title GiriE/AAY
D0 J1-1555 Jpj(ip)n 1 of 2
j 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#