Scholl, Myrtle Jan 19 18 03:39p Charlene Allen 315-347-2123 p.1
at .
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Myrtle I Scholl Female
Date of Death Age if Veteran of U.S.Armed Forces,
01/18/2018 98 Years War or Dates
i— Place of Death Hospital, Institution or
WCity, Town or Village Johnsburg Town Street Address Adirondack Tri-Courtly Nursing Arid Rehabilitation Center,Inc.
p Manner of Death Egi Natural Cause El Accident ❑Homicide Suicide ❑Undetermined ❑Pending
Circumstances Investigation
yyi Medical Certifier Name Title
James Hindson MD
Address
112 Ski Bowl Rd,Johnsbury Town,New York 12853
Death ate Filed , y�� District Number Register Number
City, llage rf ' 5655 5
❑Burial Date Cemetery or Crematory
0111912018 Pine View Crematorium
['Entombment Address
®Cremation Queensbury, New York
Date Place Removed
Z
Removal and/or Held
and/or Address
Hold
0 Date Point of
11)Q Transportation Shipment
by Common Destination
Carrier
�]Disinterment Date Cemetery Address
Reintermen# Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Aller,Denesha Funeral Home 00050
Address
Po Box 12,Dekalb Junction,New York 13630
Name of Funeral Firm Making Disposition or to Whom
1-- Remains are Shipped, If Other than Above
2 Address
w
°' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01119/2018 Registrar of Vital Statistics %age=C.Loral g ectremcatTySfgned)
(signature)
District Number 5B55 Place North Creek, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Ill Date of Disposition i/zi I I _ Place of Disposition P
(address)
CO
(section) (lot number) (grave number)
p Name of Sexton or Person in Charge of Prem es ( J
��, ••
Z se
Pit)
Signature a Title kmt91?'L
(over)
DOH-1555(02/2004)