Schmidt, George E. •
NEWYORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
George Schmidt Male
Date of Death Age If Veteran of U.S. Armed Forces,
10/27/2018 66 Years War or Dates
Place of Death Hospital, Institution or
City, Town or Village Saratoga Springs Street Address Saratoga Hospital
Manner of Death X❑Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
Medical Certifier Name Title
Romel Gobunsuy MD
Address
211 Church St,Saratoga Springs,New York 12866
Death Certificate Filed District Number Register Number
City, Town or Village Saratoga Springs 4501 569
®Burial Date Cemetery or Crematory
10/31/2018 Pine View Cemetery
❑Entombment Address
❑Cremation Queensbury Town, New York
Date Place Removed
❑Removal and/or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment
by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home William J Burke&Sons Funeral Home 01827
Address
628 N Broadway,Saratoga Springs,New York 12866
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 10/30/2018 Registrar of Vital Statistics John I'ErancR E(ectronica((y Signed)
(signature)
District Number 4501 Place Saratoga Springs, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 1 1 /1 /201f8ace of Disposition Pine View Cemetery Qii c nshury NY
(ad rress)
Seneca 34—A 1
(section) lot number) (grave number)
Name of Se n or Person in Charge of Premises Connie L. Goedert
(please print)
Signature ' Title Cemetery Superintendent
(over)
DOH-1555 (02/2004)