Schouten, Eldoris ntf
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Eldoris Marie Schouten Female
Date of Death Age If Veteran of U.S. Armed Forces,
11/03/2017 83 Years War or Dates
Place of Death Hospital, Institution or
City, Town or Village Queensbury Town Street Address Westmount Health Facility
Manner of Death fJ Natural Cause El Accident 0 Homicide Suicide El Undetermined ri Pending
Circumstances Investigation
Medical Certifier Name Title
Roslyn Socolof MD
Address
42 Gurney Ln,Queensbury Town,New York 12804
Death Certificate Filed District Number Register Number
City, Town or Village Queensbury 5657 136
❑Burial Date Cemetery or Crematory
11/06/2017 Pine View Crematory
❑Entombment Address
Cremation Queensbury Town, New York
Date Place Removed
17 Removal and/or Held
and/or Address
Hold
Date Point of
Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M B Kilmer Funeral Home-South Glens Falls 01078
Address
136 Main St,S Glens Falls,New York 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 remains described above as indicated.
Date Issued 11/06/2017 Registrar of Vital Statistics Caroline If Barber FCectronica1CySigned
(signature)
District Number 5657 Place Queensbury, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition la 'IS I r) Place of Disposition
(address)
(section) (lot number) c (grave number)
Name of Sexton or Person in Charge of Premiss //Astir �J tmirl
ase print)
Signature a Title alM MVO
-
(over)
DOH-1555(02/2004)