Runkowski, Elizabeth It 1
NEW YORK STATE DEPARTMENT OF HEALTH , N. "�
Vital Records Section Burial - Transit Permit
Name Firsclizabeth Middle LiVinkowski Sex Female
Dateo1 $lla Age_years If Veteran of U.S. Armed Forces,
j/3) �l — War or Dates
Place of Death Hospital, Institution or
2 City, Town or Village Town Of Milton Street Address Gateway House Of Peace
Iii▪ Manner of Death Q Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
ICJ Circumstances Investigation
in Medical Certifier Name Title
Susan Dorsey M.D.
Adrhhilist Ave, Saratoga Springs Ny 12866
�Certific� Milt District Number Register Number
own or on 4561
❑Burial Date 02/02/2015 Cemetery iView Cemetery
is ❑Entombment Address
[gCremation ueensbury N Y
Date Place Removed
❑Removal and/or Held
and/or
Address
Hold
cn
0 Date Point of
tL❑ ransp T ortation Shipment
Es by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Regis0f3�b4 Lion Number
Name of Funeral Home Compassionate Funeral Care 0
Address
402 Maple Avenue, Saratoga Springs, Ny 12866
Mi Name of Funeral Firm Making Disposition or to Whom
14 Remains are Shipped, If Other than Above
;; Address
re
t
, Permission is hereby granted to dispose of the h ains descr' ed abo as i 'c e
Date Issued 02/02/2015 Registrar of Vital Stati . ;_ U
(si nature)
Niii District Number 4561 Place Milton
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k
Date of Disposition 2 f311r Place of Disposition ,,1zil,-; C4,0-ct 9_—
1 (address)
CC (section) jot number) (grave number)
ev Name of Sexton or Person in harge of Premises
A (pl6 ase print)
) Signature Title CrAMAYYr`IL,
im
(over)
DOH-1555 (02/2004)