Srokowsk, Shawn Keith Jritt
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Shawn Keith Srokowski Male
Date of Death Age If Veteran of U.S.Armed Forces,
02/15/2021 43 Years War or Dates
Place of Death Hospital,Institution or
W City,Town or Village Ballston Spa Village Street Address 149 Bath Street 2,Ballston Spa Village,New York 12020
p Manner of Death ❑Natural Cause Accident Homicide Suicide ❑Undetermined ❑X Pending
W U Circumstances Investigation
W Medical Certifier Name Title
0 David DeCelle Coroner
Address
40 McMaster Street,Ballston Spa,New York 12020
Death Certificate Filed District Number Register Number
City,Town or Village Ballston Spa Village 4520 6
▪Burial Date Cemetery,Crematory or Facility Name
02/17/2021 Pine View Crematory
Entombment Address
X❑Cremation Queensbury Town,New York
❑Donation
Removal Date Place Removed
and/or and/or Held
N Hold Address
0
a Date Point of
co ❑Transportation Shipment
Q by Common
Carrier Destination
Disinterment
Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Compassionate Funeral Care Inc 00364
Address
402 Maple Ave,Saratoga Springs,New York 12866
Name of Funeral Firm Making Disposition or to Whom
1— Remains are Shipped,If Other than Above
• Address
W
a. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 02/17/2021 Registrar of Vital Statistics 7eriLeeOConnosgkctronicaf SWflt'O
(signature)
District Number 4520 Place Ballston Spa Village, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition 2-I 19 I it Place of Disposition l _t L
W (address)
W
CC (section) (lot n�mber) r (grave number)
� /] c , J\A,�
Name of Sexton or Person in Charge of Premi s 't,' wit
(please pri
W ( Title ( A I}�
Signature
DOH-1555(o7/18)p t of 2
Public Health Law Sec. 4145(2b) ,, b '
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#