Schaeffer, Carol NEW YORE STATE DEPARTMENT OF HEALTH Vitat-Records Section Burial - Transit Permit
Name First Middle Last Sex
Carol S. Schaeffer Female
Date of Death Age If Veteran of U.S. Armed Forces,
12/27/2018 65 War or Dates NA
F., Place of Death Hospital, Institution or
Z City, Town or Village Queensbury,NY Street Address 9 Martell Rd.Queensbury,NY 12804
vManner of Death I A I Natural Cause n Accident 0 Homicide pi Suicide n Undetermined 1 Pending
Circumstances Investigation
W Medical Certifier Name Title
O David Cunningham MD
Address
3 Irongate Center,Glens Falls,NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village Town of Queensbury,NY 5(0 ji I 5,D
®Burial Date Cemetery or Crematory
Entombment 12/31/2018 Pine View Cemetery
Address
❑Cremation Quaker Road,Queensbury,NY 12804
Date Place Removed
Z n Removal and/or Held
2 and/or Address
�' Hold
N
a Date Point of
y ❑Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Ei
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Road,Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
I- Remains are Shipped, If Other than Above
a Address
CZ
U.1
D.
Permission is hereby granted to dispose of the human re s es bo s indicated.
Date Issued I(9..-, ,S-1� Registrar of Vital Statistics D
(signature)
District Numberg161 Place lO ,h
kf2.Qin j)LV
I certify that the remains of the decedent identified abov ere disposed of in acco nc with this permit on:
Z
UJ Date of Disposition) 2/31 /201 apiece of Disposition ine View Ce to
W (address)
U) Erie 74-D 2
re
(section) (lot number) (grave number)
p Name of S on or Person in Charge of Premises Connie L. Goedert
Z (please print)
W Signature K.ic.C9,.. v.. `�-d( Title Cemetery Superintendent
(over)
DOH-1555(02/2004)