Rubaszek, Stephan (C0O
NEW YORK STATE DEPARTMENT OF HtALT H'
Vital Records Section Burial - Transit Permit
Name First Stephan Middle Last SexSex Male
Date of Death Age If Veteran of U.S. Armed Forces,
10/07/2013 53 years War or Dates
Place of Death Hospital, Institution or
Z Cif9(Xgwn or VillfiVAXX Greenfield Street Address 529 Sodeman Road
14I-
Manner of Death❑I►ratural Cause D Accident 0 Homicide 0 Suicide �Undetermined Pending
tLi Circumstances Investigation
tu Medical Certifier Name Title
0 Paul Okosky M D
Address Route 50, Saratoga Springs, New York
Death Certificate Filed District Number Register Number
Ci4Woin or ViowXX Greenfield 4557 15
0Burial Date Cemetery or Crematory
10/10/2013 Pine View Crematorium
i ❑Entombment Address
❑Ofemation Queensbury, New York
Date Place Removed
K.❑Removal and/or Held
"'
and/ldor Address
Cl)
Ho
O Date Point of
63 Q Transportation Shipment
0 by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Q Renterment Date Cemetery Address
>: Permit Issued to Registration Number
Name of Funeral Home Compassionate Funeral Care, Inc. 00364
Address 402 Maple Avenue, Saratoga Springs, N Y 12866
g. Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Ir.
f
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 10/10/2013 Registrar of Vital Statistics
(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:
iti Date of Disposition / U//-/3 Place of Disposition A,✓' V/r 014till AAA/
2 (address)
tki
VI
CC (section) number) I (grave number)
et
Name of Sexton o Pers in rge of Premises S,Co 74 vo )�✓i G/
z (please print)
Signature /� 4 Title �_ r...7 v/L i,
c
(over)
DOH-1555 (02/2004)