Black, Shirley I I/0
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
mi Name First Middle_ Last Sex
Shirley S. Black Female
Date of Death Age If Veteran of U.S. Armed Forces,
07 / 03 / 2016 92 War or Dates N/A
Place of Death Hospital, Institution or
ZCity, Town or Village Saratoga Springs Street Address Saratoga Hospital
0 Manner of Death®Natural Cause 0 Accident 0 Homicide El Suicide 0 Undetermined �Pending
Ui Circumstances Investigation
iii Medical Certifier Name Title
Q William M. Kufs MD
Address
6 Care Ln, Saratoga Springs, NY 12866
Riii Death Certificate Filed District Number -f tot Register Numbero�
>: City, Town or Village Saratoga Springs ` `
0Burial Date Cemetery or Crematory
07 / 05 / 2016 Pine View Crematory
IN LIEntombment Address
iigi Cremation Queensbury, NY
Date Place Removed
Z❑Removal and/or Held
and/or Address
t Hold
0 Date Point of
Q Transportation Shipment
tit❑
C by Common Destination
Carrier
a
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
i!p1;1 Name of Funeral Home Compassionate Funeral Care, Inc 00364
Vii Address
402 Maple Ave. , Saratoga Springs, NY 12866
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
IIL
Permission is h reby granted to dispose of the human remains ibe above s indicated.
Date Issued 1 5 li 0 Registrar of Vital Statistics 1 . qttub.rulk
(signature)
District Number it- LI
Place Saratoga Springs , New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
lit Date of Disposition '7 f 1a(f{, Place of Disposition 'POULa ,� -h,e+--
(address
U1
Cr (section) (lot number) (grave number)
;Q Name of Sexton or Person ip Charge of Premises ' c .a. �i
z /'� (pl se print) .
til Signature L-r - Title 1 4�(
(over)
DOH-1555 (02/2004)