Skrika, Richard NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
igii Name First Middle Last Sex
Richard Steven Skrika Mal
Date of Death Age If Veteran of U.S. Armed Forces,
qp February 6, 2017 69 War or Dates N/A
14 Place of Death Hospital, Institution or
City, Town or Village Saratoga Springs Street Address Saratoga Hospital
ci Manner of Death Natural Cause 0 Accident 0 Homicide Ej Suicide 0 Undetermined El Pending
tti Circumstances Investigation
III Medical Certifier Name Title
Mark Weidner MD
Address
211 Church Street, Saratoga Springs, NY 12866
Death Certificate Filed District Number Register Number
City, Town or Village Saratoga Springs 4501
❑Burial Date Cemetery or Crematory
February 7, 2017 Pineview Crematory
s'0 Entombment Address
:=[Cremation 21 Quaker Road, Queensbury, NY 12804
Date Place Removed
❑and/or
Removal and/or Held
M,�; Address
til Hold
Date Point of
[]Transportation Shipment
Ci by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
c Permit Issued to Registration Number
Name of Funeral Home Compassionate Funeral Care, Inc. 00364
Address
402 Maple Avenue, Saratoga Springs, NY 12866
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
tr
ttt
Permission is hereby granted to dispose of the human remainsribe abouq;ws-ice icated.
l Date Issued 2/6/2017 Registrar of Vital Statistics .'' , �✓
ip (signature)
>i District Number 4501 Place City Hall, Saratoga Springs, NY 12866
IN
k``" I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
p
II Date of Disposition Zlglr1 Place of Disposition lent U,r../ L;^*wfo t'ru-s
(address)
iti
Ul
(section) l (lot number) - (grave number)
, , Name of Sexton or Person in Charg of Premises 1Ar,�k Stni/4-
Z ,,, (p se print)
Signature 61 %.?" Title ANE-10AN,
(over)
DOH-1555 (02/2004)