Paskiewicz, Robert it
ti- 6 fi
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Robert PG s K/ e W i• C 2 Male
Date of Death Age If Veteran of U.S. Armed Forces,
09 / 14 / 2017 75 War or Dates N/A
Place of Death Hospital, Institution or
Z City, Town or Village Wilton Street Address 54 Loughberry Mobile Home Park
Ili
0 Manner of Death®Natural Cause E Accident Homicide ❑Suicide ❑Undetermined �Pending
IliCircumstances Investigation
tgl Medical Certifier Name Title
P Edward M. Liebers MD
Address
3 Care Ln #300, Saratoga Springs, NY 12866
Death Certificate Filed District Number Register Number
iiM City, Town or Village Wilton
Burial Date Cemetery or Cre ``�
-q
® o rY 09 / 18 / 2017 Pine View Crematory
fl Entombment Address
Cremation Queensbury, NY
Date Place Removed
❑Removal and/or Held
and/or Address
Hold
O Date Point of
Q Transportation Shipment
o by Common Destination
Carrier
El Disinterment Date Cemetery Address
Q Renterment Date Cemetery Address
<1 Permit Issued to Registration Number
Ai Name of Funeral Home Compassionate Funeral Care 00364
Mil Address
402 Maple Ave., Saratoga Sp. , NY 12866
iiiii
iiili Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
• Address
ilk
iti
.. Permission is hereby ranted to dispose of the human remains described above as indicated.
Rii Date Issued r Registrar of Vital Statistics 07/i/ a yi4editir,(signs a:i:2 District Number • /j Place Wilton , New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
111 Date of Disposition t{+)ilf) Place of Disposition ?lulkf ,,,,.dtc.--
2 (address)
in
11 (section) 45 number) (grave number)
0 Name of Sexton or Person in Charge of Pre ises N Il S D�hsq'
z •4'/ (piee�se print) •
t4 Signature /��',{ Title f l tPuI1
(over)
DOH-1555 (02/2004)