Russo, Sally NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit
Name First Middle Last Sex
Sally Wise Russo Female
Date of Death Age If Veteran of U.S. Armed Forces,
gp 03/13/2015 77 years War or Dates
f- Place of Death Hospital, Institution or
ii Town or)(Wpm Wilton Street Address 15 Thistle Road
Manner of Death Ei,Natural Cause ElAccident ❑Homicide 0 Suicide ❑Undetermined ❑Pending
W. Circumstances Investigation
ILI Medical Certifier Name Title
Edward M Liebers Md
Address
3 Care Lane, Saratoga Springs, NY 12866
igiiii Death Certificate Filed District Number Register Number
in jObtxTown or Wilton 4569 17
❑Burial Date Cemetery or Crematory
ID Entombment 03/16/2015 Pine View Cemetery
Address
: ❑Cremation Queensbury
Date Place Removed
.. ❑Removal and/or Held
.,,. and/or
Address
Ca
Hold
0 Date Point of
Transportation Shipment
5 by Common Destination
Carrier
El Disinterment Date Cemetery Address
ii,gOR
❑Reinterment Date Cemetery Address
gilPermit Issued to Registration Number
Name of Funeral Home Compassionate Funeral Care, Inc 00364
iliM Address
402 Maple Ave. Saratoga Springs N Y 12866
iiiii Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
C
LAI
Permission is hereby granted to dispose of the human remains described above as indicated.
liii Date Issued 03/16/2015 Registrar of Vital Statistics /74, /W4
(si na )
District Number 4569 Place Wilton
>_:_ I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
LEI Date of Disposition 3/4 i r Place of Disposition „v,a-1 .r-
(address)
1-11
(section) `, (lot n mber) (grave number)
et Name of Sexton or Per n in Charge of Premises G *1''' 3umit
Z (please print)
Signature 4 Title (11: ,fly .
(over)
DOH-1555 (02/2004)