Schmonsky, Richard f * ,...)
NEW YORK STATE DEPARTMENT OF HEALTH -i / S 9
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Richard Schmonsky Male
Date of Death Age If Veteran of U.S. Armed Forces,
03 / 11 / 2016 68 War or Dates
-- Place of Death Hospital, Institution or
iZ City, Town or Village Malta Street Address 5 Rainbow Way
t Manner of Death®Natural Cause E Accident Homicide D Suicide "-I Undetermined 0 Pending
1111Circumstances Investigation
tit Medical Certifier Name Title
a Edward M Liebers MD
Address
3 Care Ln # 300, Saratoga Springs, NY 12866
. Death Certificate Filed District Number Register Number
igli City, Town or Village Malta
< OBurial Date Cemetery or Crematory
03 / 14 / 2016 Pine View Crematory
I
Mii O Entombment Address
:j ECremation Queensbury, NY
Date Place Removed
r❑Removal and/or Held
and/or Address
Hold
Date I Point of
Q Transportation I Shipment
by Common Destination
Carrier
ill
0 Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
>' Permit Issued to Registration Number
Name of Funeral Home Compassionate Funeral Care, Inc 00364
>> Address
402 Maple Ave. , Saratoga Springs, NY 12866
i<i Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
t
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued j f j Registrar of Vital Statistics . -j_A,�, g
(signs i�
District Number c/.5:4-Ees Place Malta , New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ta \,
Date of Disposition 3/A5'�l� Place of Disposition -Pm �+.• rim
of - .
Z (address)
cc (section) / (lot number) . (grave number)
CIName of Sexton or Person ip Char a of Premises bl�� f Ss,wi
10 a '
Signature Title ( -
(over)
DOH-1555 (02/2004)