Rubaszek, Lorraine T J� c�
NEW YORK STATE DEPARTMENT OF HEALTH l+ Xv i
Vital Records Section Burial - transit Permit
- Name First Middle Last Sex
Lorraine Rubaszek Female
Date of Death Age If Veteran of U.S. Armed Forces,
11/22/2015 52 years War or Dates
Place of Death Hospital, Institution or
own orStreet
CX�X� ���( Greenfield AddressGreenfield Cemetery
Manner of Death❑Natural Cause ElAccident ElHomicide Suicide ❑Undetermined El Pending
Circumstances Investigation
W Medical Certifier Name Title
Q Daniel J. Kuhn Coroner
Address
40 Mcmaster Street, Ballston Spa, N Y 12020
Death Certificate Filed District Number Register Number
CX own or vleirlitX Greenfield 4557 21
❑Burial Date Cemetery or Crematory
['Entombment12/01/2015 Pine View Crematorium
Address
Eremation Queensbury. New York
Date Place Removed
Z Removal and/or Held
- and/or Address
U) Hold
O Date Point of
tL Transportation Shipment
▪ by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Compassionate Funeral Care, Inc. 00364
Address
402 Maple Avenue, Saratoga Springs, N Y12866
Name of Funeral Firm Making Disposition or to Whom
to Remains are Shipped, If Other than Above
• Address
w
P Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11/25/2015 Registrar of Vital Statistic
(signature)
District Number 4557 Place Greenfield
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
tU Date of Disposition it it I i Place of Disposition ��,� cleSt
(address)
U i
ilk
cc (section) (lot number) (grave number)
a
/� C
a Name of Sexton or Person in Charg of Premises G hri lit 31.0044
(p/ ase print)
Signature Title ftif+'t l ft-
(over)
DOH-1555 (02/2004)