Schenk, Roland NEWYORkTATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Roland M. Schenk Male
Date of Death Age If Veteran of U.S. Armed Forces,
May 18, 2013 89 War or Dates World War II
Place of Death Hospital, Institution or
w City, Town or Village Glens Falls Street Address Glens Falls Hospital
WManner of Death Natural Cause ❑ Accident ❑ Homicide ❑ Suicide n Undetermined Pending
W Circumstances Investigation
W Medical Certifier Name Title
CI Dean Reali, MD,
Address
Glens Falls Hospital Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village 5601 2 1 '
®Burial Date Cemetery or Crematory
May 24, 2013 Pine View Cemetery
❑Entombment Address
y '❑Cremation Quaker Rd. Queensbury,NY 12804
Date Place Removed
z riRemoval and/or Held
p, and/or Address
_p Hold Pine View Cemetery
CO Date Point of
f, I I Transportation Shipment
_ by Common Destination
CI' Carrier
Disinterment Date Cemetery Address
ElReinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped, If Other than Above
Address
IX
t3. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 5 / 2-/ /(3 Registrar of Vital Statistics u„.}C ,s? W
(signature)
District Number 5601 Place s 1__-Ed \5 ) iN,)
C�
i- I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 5/24/1 3 Place of Disposition Pine View Cemetery
2' (address)
W Oneida 96 2
;` (section) (lot number) (grave number)
0C3'' Name of Se or Person in Charge of Premises Connie T,_ CoPclPrt
(please print)
W; Signatur- IIK4 ` o-`- Title Superintendent
(over)
DOH-1555 (02/2004)