Wolfram, Schille ,a t I I'S
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial Transit Permit
Name First Middle Last Sex
iA Wolfram J. Schille Male
Date of Death Age If Veteran of U.S. Armed Forces,
1w 12/12/2018 82 War or Dates 1959-1962
?O' Place of Death Hospital, Institution or
City, Town or Village Town of Queensbury,NY Street Address 384 Cleverdale Rd.
Manner of Death r Natural Cause L Accident n Homicide E Suicide ri Undetermined n Pending
Circumstances Investigation
Medical Certifier Name Title
Robert Evans DO
- Address
1 Irongate Center,Glens Falls,NY 12801
t Death Certificate Filed District. Number Register tuber
City, Town or Village Town of Queensbury,NY :>C I i
El Burial Date Cemetery or Crematory
El Entombment December 14, 2018 Pine View Crematorium
Address
®Cremation 51 Quaker Road, Queensbury,NY 12804
Date Place Removed
Z El Removal and/or Held
O and/or Address
�` Hold
th
0 Date Point of
N`El Transportation Shipment
p by Common Destination
Carrier
n Disinterment Date Cemetery Address
n Renterment Date Cemetery Address
µ Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Road,Queensbury,NY 12804
h 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 describ d above as indicated.
s ri Date Issued 3\k�1 1 Registrar of Vital Statistics �G.,, G S-^----^
----- (signatu )
District Numbe ( 1 Place , \ O
1- I certify that the remains of the decedent identified above were disposed of in accordance with this permit o
Z V
W' Date of Disposition I Vie/lk Place of Disposition j;ne tw Cr'er,4,4w.,,r,
2 (address)
W
N
(section) (lot number) (grave number)
p' Name of Sexton or Person in Charge of Premises 1 �l`��( l�r,r .l It
Zr (please print)
w Signature 2Z ' - Title Car.,..4-a.
(over)
DOH-1555(02/2004)