Schult, Russell #NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Russell W. Schult Male
• Date of Death Age If Veteran of U.S. Armed Forces,
01/17/2017 65 years War or Dates
}- Place of Death Hospital, Institution or
• City, TWO X Saratoga S rims Street Address 57 gallcton Ave Apt 210
• Manner of Death❑,Natural Cause Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
US Circumstances Investigation
Medical Certifier Name Title
James Craig M D
Address
1 Tallow Drive, Clifton Park, N Y 12065
Death Certificate Filed District Number Register Number
City, Tom*QX Saratoga Springs 4501 28
❑Burial Date Cemetery or Crematory
❑Entombment 01/23/2017 Pine View Crematory
Address
DCremation Queensbury, N Y
Date Place Removed
Z Removal and/or Held
❑• and/or Address
Hold
a Date Point of
Transportation Shipment
0 by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Compassionate Care, Inc. 00364
Address
402 Maple Avenue, Saratoga Springs, N Y 12866
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped, If Other than Above
2 Address
CC
W
a' Permission is hereby granted to dispose of the human remain descr Atolls'i dicated.
Date Issued 01/20/2017 Registrar of Vital Statistics
(signature)
District Number 4501 Place Saratoga Springs
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W• Date of Disposition 1/z6117 Place of Disposition Q ,�.� (pvrr, ot-.
W (address)
f1)
cc (section) (lot number) C (grave number)
pName of Sexton or Person in Charge of Premises `irJ J,41fi
W ( lease print)
Lk
Signature s Title
(over)
DOH-1555 (02/2004)