Ambrozak, Patricia (p®_5
NEW YORK STATE DEPARTMENT OF HEALTH b
Vital Records Section Burial - Transit Permit
Name Fir Middle L stAim Sex
vatricia brozak Female
Date of Death Age If Veteran of U.S. Armed Forces,
10/04/2013 75 years War or Dates
}- Place of Death Hospital, Institution or
X City, TXJ KSOV�IIX ( Saratoga Springs Street Address 550 Union Avenue, Saratoga Hospital, N Y
Manner of Death❑Natural Cause 0 Accident J'Homicide Suicide riUndetermined 0 Pending
US Circumstances Investigation
tu Medical Certifier Name Title
L Susan Hayes-masa Coroner
Ad 9scrand Ave., Saratoga Springs, NY
Death Certificate Filed District Number Register Number
City, TUKSOVIIIMA Saratoga Springs 4501 404
❑Burial Date Cemetery or Crematory
10/11/2013 Pine View Crematorium
ii',❑Entombment Address
;;;: IICremation Queensbury, N Y
Date Place Removed
Z Removal and/or Held
9❑and/or Address
H Hold
0 Date Point of
ili❑Transportation Shipment
0 by Common Destination
Carrier
Q Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
iiiPermit 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
Address
i
l
` Permission is hereby granted to dispose of the human remai ib ab ' dicate
Date Issued 10/08/2013 Registrar of Vital Statistics
(signature)
Ell 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:
Z
ill Date of Disposition/O 1//3 Place of Disposition 19j%✓,,< Vek/ Ceed,..tryi-rr
(addres
ILEA
0
CC (section) num er) d (grave number)
CV
ci Name of Sexton o er n in arge of Premises <CP
2 /� I(ppllease print )
41 Signature d Title (�s rn.°�' /1- ifil
(over)
DOH-1555 (02/2004)