Schmidt, Mabel NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Vital Records Section
Name First Middle Last Sex
MABEL O. SCHMIDT Female
Date of Death • • Age If Veteran of U.S.Armed Forces,
'''' Aug. 12, 1993 79 War or Dates No Pi
Place of Death Hospital, Institution or
W QO,Towrc Indian Lake Street Address Residence Durant Rd.
Q Manner of Death....:: :...:..... .. :::.................. _:......: .:..... Undetermined Pending
icii41 Natural Cause ❑ Accident ❑Homicide Suicide
Circumstances Investigation
W Medical Certifier Name Title -.1
$ Russell...E„ Ryder.. M.D..... ...........:..
Ni Address
:::::::;::
........::..: _ .................P 4..:..Box...579.,....long Lake,:.:N...Y.:.::.1:.2.847.....
iE Death Certificate Filed District Number Register Number
Off t,Townes Indian Lake 2053 7
Date Cemetery or Crematory
❑Burial
rEsCremation Address
Queensbury, N.Y. 12804
z Date Place Removed
0I Q Removal and/or Held
H and/or Hold ....:::............... .....:.::
Address
o.... :.:.::............................................................................ ..
•a Date Point of
in ❑Transportation by Shipment
p Common Carrier
Destination
❑ Disinterment
Date Cemetery Address
▪ Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Firm
ni Address
North..River,..N.Y.:::. : . ..:.. .:::::.
4.4 Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
wi
�: Address
Permission is hereby granted to dispose of the huma
remains described above as indicated.
iiiiiiiiii Date Issued Auq, 13, 1993 Registrar of Vital Statistics 4 1?), LG
Aal
(signature)
District Number 2053 Place Town Clerk's Office, Indian Lake, N.Y.
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
H i . , ' / _ /jam
W Date of Disposition /p `Place of Disposition ,/V�j/d 41 ,/r, 7%1jg/-d�,'2J,4'/
2I (address)
w
cc (section) (lot number) (grave number)
g ,-27�/9lrf� �I/97i /1t�p, Name of Sexton or erson in C arge of Premi es
W Signature (please print) Title (g,k--/ii/9 Tit' /yjsJ /
DOH-1555 (10/89) p. 1 of 2 VS-61