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Ruiz Sr., Joseph NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex - Joseph Patrick Ruiz Sr. Male Date of Death Age If Veteran of U.S.Armed Forces, 11/16/2017 77 Years War or Dates' Place of Death Hospital, Institution or City,Town or Village Ballston Spa Village Street Address Saratoga Center for Rehab and Skilled Nursing Manner of Death©Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending Circumstances Investigation Medical Certifier Name Title Vina Patel MD Address 149 Ballston Ave,Ballston Spa Village,New York 12020 Death Certificate Filed District Number Register Number City, Town or Village Ballston Spa Village 4520 79 Burial Date Cemetery or Crematory 11/21/2017 Pine View Cemetery Entombment Address ❑Cremation Queensbury, New York Date Place Removed ❑Removal and/or Held and/or Address Hold Date Point of ''❑Transportation Shipment by Common Destination Carrier ❑Disinterment Date Cemetery Address E❑Reinterment Date Cemetery Address " Permit Issued to Registration Number Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596 Address 1. 407 Bay Rd,Queensbury,New York 12804 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Address Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 11/21/2017 Registrar of Vital Statistics Teri Lee°Conno► E&ctrmica!lySigned" (signature) its District Number 4520 Place Ballston Spa Village, New York I certify that the remains of the decedent identified above were'disposed of in accordance with this permit on: Date of Disposition 1/17-1 fl Place of Dispositio %�� c �i'�t he)L' /g` fi gLeir.+� (address) (section) (lot number) (grave number) Name of Se or Person in Charge of Premises (P Print) Signature Ut • -Q tle (over) DOH-1555 (02/2004)