Sullivan, Cynthia NEW YORK STATE DEPARTMENT OF HEALTH '3
Vital Records Section • int Burial - Transit Permit
Name First Middle Last Sex
Cynthia Jyl Sullivan Female
Date of Death Age If Veteran of U.S. Armed Forces,
05/06/2014 68 years War or Dates
Place of Death Hospital, Institution or
6 City, ToIXIXXCICVXDOWX Saratoga Springs Street Address 14 Springwood Drive, Saratna Springs, NY
0 Manner of Death Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined Pending
tii Circumstances Investigation
la Medical Certifier Name Title
41 Michael Sikirica Md
Address
58 Broad St., Waterford, N Y
Death Certificate Filed District Number Register Number
City, ToiXX XXV1etIOXX Saratoga Springs 4501 220
i !!'❑Burial Date Cemetery or Crematory
05/08/2014 Pine View Crematory
❑Entombment Address
❑cremation 6Ae 1 �C Qs N Y
Date Place Removed
❑• Removal and/or Held
2 and/or Address
H Hold
SR
O Date Point of
M.❑
t/ Transportation Shipment
0 by Common Destination
Carrier
I:Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
;>; Name of Funeral Home Compassionate Care, Inc. 00364
`< Address
402 Maple Avenue, Saratoga Springs, N Y 12866
Name of Funeral Firm Making Disposition or to Whom
; Remains are Shipped, If Other than Above
2 Address
#t
II1I
! Permission is hereby granted to dispose of the human remainscr a abort? ' icated.
Date Issued 05/08/2014 Registrar of Vital Statistics
(signature)
District Number 4501 Place Saratoga Springs
:: I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILI Date of Disposition S-i-ol Place of Disposition tat," U-4-4,40.,
(address)
1U
CO
CC (section) (lot nutter) (grave number)
O Name of Sexton or Pers n in Charge of Premises i
:' �t"^
2
(please print)
W Signature Title 's
(over)
DOH-1555 (02/2004)