Schult, Helen NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
'A, Helen Frances Schutt Female
Cw
Date of Death Age If Veteran of U.S. Armed Forces,
12/25/2018 90 Years War or Dates
1= Place of Death Hospital, Institution or
ACity, Town or Village Granville Town Street Address The Orchard Nursing And Rehabilitation Centre
Manner of Death Natural Cause Accident Homicide Suicide ❑Undetermined Pending
LLf Circumstances Investigation
w Medical Certifier Name Title
Leonard Gelman MD
Address
<: 10421 State Route 40,Granville Town.New York 12832
Death Certificate Filed District Number Register Number
City, Town or Village Granville 5756 72
'kt®Burial Date Cemetery or Crematory
12/27/2018 Pine View Crematorium
❑Entombment Address
`_®Cremation Queensbury Town. New York
Date Place Removed
Z D 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 Carleton Funeral Home Inc 00281
' Address
I. 68 Main Stpo Box 67,Hudson Falls,New York 12839
Name of Funeral Firm Making Disposition or to Whom
t Remains are Shipped, If Other than Above
2 Address
Lu
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/27/2018 Registrar of Vital Statistics jenny Linda llartet7a tE(ec trenicalry�Signed
(signature)
40 District Number 5756 Place Granville, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
LU Date of Disposition Place of Disposition
(address)
a)
M (section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises
2' (please print)
Signature Title
(over)
DOH-1555 (02/2004)