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Schmidt, Ella
NEW YORK STATE DEPARTMENT OF HEALTH Vital Fecords Section Burial - Transit Permit Name First � Middle Last Sex fr LL)3- l t .�C lfi itl 16 r Fec/tat cr aDate of Death I Age 7If Veteran of U.S. Armed Forces, / / 4' 1 b'7 ; _cv�ror Dates ,J/$ '`'` P ace of Death L F1t.lospitJ)lnstitution or City, own or Village L trN S / �JZ(,S Street Address •C.6'N_S �,A'LLS anner of Death Natural Cause n Accident n Homicide 0 Suicide Q Undetermined ri Pending Circumstances Investigation g., Medical Certifier Name Title r 0-t +D 1`OaTt& �: . z _ r -...`..' Address /CO f , 4 L VT- . Ct E! FIniCS /" I Z 4>o ?� Certificate Filed I District Number ' Register Number r City, own or Village �t a-,vj F✓g2�s 1 yLi Date Cremary / l :Burial c) /2 9 If Y i /', cc' 01 6t-..) Address Cremation ALIA Date yj Place Removed Z t +Removal i and/or Held EL and/or Address Hold 0 Date -T Point of Transportation _ j Shipment =y, by Common Destination Carrier Disinterment Date Cemetery Address El Reinterment Date Cemetery Address Permit Issued to }` Name of Funeral Home it/Cyr/arc/ b, Zaker Ft-tiler-alJ/o ie Registration 11Number <� Address r lI Lcr�cz yet c or. , (NIGua�sbu-ry , /)ao L%v-IL l.1 2 Name of Funeral Firm Making Disposition or to Whom S Remains are Shipped, If Other than Above 440 Address CV LA -214 <1 : Permission is hereby granted to dispose of the human remains de ri ed ov 'ndicated, il Date Issued Q /2 /2o/y Registrar of Vital Statistics .iii (signature) iN :iiE District Number S-6©/ Place 1phe,. , A/A ,t y I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: f- t Date of Disposition 9/2 9/1 4 Place of Disposition Pine View Cemetery M. (address) Mohican 40F 2 Ix (section) (lot number) (grave number) 8 Name of Se on or Person in Charge of Premises Connie L. Goedert . � ofd:� (please print) Signature Y - Title Superintendent (over) DOH-1555 (9/98) c 'y ) `_ Lot No. Schmidt 40 F ,ddress Route 8 Box 26 Wever Town N.Y. 12886 0026 Section No. )wner Charles & Ella Schmidt Plot Mohican �ov,(,cacfi vn )ate7/7/95 Superficial ft. @ 67 .ocation Bounded North By Vacant . South By Beames , East By Scott &Morriso . West BY Bolton & Mahoney :orner Posts temarks )eed No. (and changes) 2677 'ayment Record 7/7/95 Paint Tn Full ( $700 , 00 ) tecord of Interments 4-,°�O ,Sec TT merrisow Cu-\e-- -))i-Nr) - q- -(34.. Ella May Schmidt ( 9/29/2014) 1 IW 5.aoi E / 75R nl aS—{--N X x nl S f E 5 ' 5 60IT0N 01A-H rktey B Form No. 01 IZAMF. SCHMIDT, ELLA MAY . LI) Age: 87 Cause: Natural Lot Ow er: Charles & Ella Schmidt Lot # 40 F Mohican Grave # 2 Case # Concrtee Died: 9/25/2014 interred: 9/29/2014 Undertaker: Maynard D. Baker