Schutta, Edward NEW YORK STATE DEPARTMENT OF HEALTH il bi
Vital Records Section Burial - Transit Permit
Name First Middle Last 1 Sex
Edward James Schutta I Male
Date of Death I Age N If Veteran of U.S. Armed Forces,
.t:,,i,
So 12/21/2018
85 War or Dates After 1/31/55
' Place of Death tAYOGI LC,50 Hospital, Institution or v �JQ,T �4,
'1 City,Town or VillageCjaectgFtewn Street Address Deceased's Residence
Manner of Death Natural Cause all Accident El Homicide 0 Suicide ❑Undetermined El Pending
Circumstances Investigation
Lti
Medical Certifier Name `�� Title
rotl
Joseph C. Mihinda,
Address
I
20 Murray St. Glens Falls, NY 12801
Death Certificate Filed ,/ District Number Register Nu be
City,Town or Village �i'l/CEP-eilic�l>f - ,.���
�T ❑Burial Date r Crem v
iik 12/24/2018 C ► rak , l�l rG.6l' �d '/b'7G'r�j
❑Entombment Address J� O
®Cremation �� c�
,„,„
7
r„ Date PIS..3 Removed
Z Removal anr,'or Held
I and/or Address
Ntit Hold
Date Point of
Transportation Shipment
by Common Destination
Carrier
`' Date CemeteryAddress
, Disinterment
Reinterment Date Cemetery Address
,o ° Permit Issued to Registration Number
,yam Name of Funeral Home Barton-McDermott Funeral Home, Inc. 00141
'';z Address
;102, 9 Pine St/P.O. Box 455 Chestertown NY 12817
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby ranted to dispose of the human remains de ribed above as indicated.
mg
'' Date Issued /'' .J /S Registrar of Vital St . 1)
(signature)
District Number:37 6 o Place 0(Z-IYI S�u
I
41 I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition la--J. -i Place of Disposition p;„ _, v,t.,,,„/ G M,it.tq tory
(address)
(section) (lot number) (grave number)
tName of Sexton or Person in Charge of Premises J e,'i y bv.h I cs
5 ;; (please print)
�: Signature %/i,vm.7 / .) Title (s!-t la
7
(over)
DOH-1555(02/2004)