Schouten, Karen t. ___ i it 71C,
NEW YORK STATE DEPARTMENT OF HEALTH :\
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Karen Jones Schouten Female
Date of Death Age If Veteran of U.S. Armed Forces,
04 / 03 / 2017 65 War or Dates N/A
Place of Death Hospital, Institution or
City, Town or Village Saratoga Springs Street Address 1 S Federal St Apt 503
Iii
Manner of Death®Natural Cause E Accident 0 Homicide E Suicide 7 Undetermined 0 Pending
Circumstances Investigation
0.
til Medical Certifier Name Title
Michael Sikirica MD
Address
50 Broad St. , Waterford, NY 12888
> Death Certificate Filed District Number i Register Number
"< City, Town or Village Saratoga Springs 5 ( Q
oBurial Date Cemetery or Crematory /
04 / 06 / 2017
ilEntombment Pine View Crematory
Address
Cremation Queensbury, NY
Date Place Removed
Z❑Removal and/or Held
and/or Address
Hold
Date Point of
1Q Transportation Shipment
5 by Common Destination
iii Carrier
:: Q Disinterment Date Cemetery Address
'`<< Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
iN Name of Funeral Home Compassionate Funeral Care 00364
: Address
402 Maple Ave., Saratoga Sp., NY 12866
i, Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
IL
.14 :::
is h reb granted to dispose of the human rem ' s de jritcy.,,iab*) indicate
qi
11 Registrar of Vital Statistics
(signature)
i District Number L Place Saratoga Springs , New York
IV
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
fi:A0, 1I� Date of Disposition �- f 0�-i� Place of Disposition sue/ �v `,_.
(address)
CO
IC (section) (lot numb (grave number)
CI Name of Sexton or Person Char a of Premises I' i it
Z g
/(pleas(t/Ji1,L.
not .
Signature Title _
(over)
DOH-1555 (02/2004)