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Schenk, Clara a NEW YORK STATE DEPARTMENT OF HEALTH 1o4i Vital Records Section Burial - Transit Permit Name First Middle Last Sex Clara Mae Schenk Female Date of Death Age If Veteran of U.S. Armed Forces, May 17, 2018 79 War or Dates Place of Death Hospital, Institution or City, Town or Village South Glens Falls Street Address 14 Chestnut Street Manner of Death Natural Cause ❑ Accident Homicide 0 Suicide ❑ Undetermined ❑ Pending Circumstances Investigation Medical Certifier Name Title Karen L. Zanni, Address 3 Irongate Center Glens Falls, NY 12801 Death Certificate Filed District Number Register Number City, Town or Village South Glens Falls 0 Burial Date Cemetery or Crematory de, May 22, 2018 Pine View Crematory 0 Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed 2 ❑ Removal and/or Held and/or Address Hold Date Point of ❑Transportation Shipment Olt by Common Destination I Carrier Date Cemetery Address El Disinterment ❑ Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home M.B. Kilmer Funeral Home-SGF 01078 Address 136 Main Street, South Glens Falls NY 12803 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 remain described above as indicated. Date Issued 5/2/A2O/g Registrar of Vital Statistics (signature) District Number 5a9 Place V l/(Q9 p o sDki-h Glevis (.1. . s„,, I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition 05/22/2018 Place of Disposition Quaker Road Queensbury,NY 12804 (address) l (section) (lot number) (grave number) 4-�( Name of Sexton or Person in Charge of Premises I^�r• -�'��1t �j lease print) fi Signature Jr- Title avotiOrt- (over) DOH-1555 (02/2004)