Schultz, Gladys NEW YORK STATE DEPAR. :T OF HEALTH Burial - Transit Permit
Vital Records Section
_ Name First Middle Last Sex
GLADYS _ E. SCHULTZ FEMALE
Date of Death Age If Veteran of U.S.Armed Forces,
11/17/2016 70 War or Dates NO
!r Place of Death Hospital, Institution
Z City ,Town or Village City of Albany or Street Address ALBANY MEDICAL
O Manner of Death ❑ Natural 1771 Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
w Cause Circumstances Investigation
W Medical Certifier Name Title
p PAUL MARRA MD
Address
112 STATE ST. ALBANY NY 12207
Death Certificate Filed District Number Register Number
City,Town or Village City of Albany 101 2410
Date Cemetery or Crematory
❑ Burial 11/18/2016 PINEVIEW CREMATORY
D Entombment Address
® Cremation QU.EENSBURY, NY
Date Place Removed
Z Removal and/or Held
2. ❑ and/or Address
F- Hold
O Date Point of
p_ Transportation Shipment
to ❑ By Common Destination
p Carrier
❑ Disinterment Date Cemetery Address
ElDate Cemetery Address
Reinterment
Permit Issued To Registration Number
Name of Funeral Home BREWER FUNERAL HOME 00211
Address
24 CHURCH ST. LAKE LUZERNE NY 12846
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Z' Address
111
Q Permission is hereby granted to dispose of the human remains describ ab ve asindicated Lv .
C (.S
Date 11/17/2016 Registrar of Vital Statistics � ,��-
Issued (sign ture)
District Number 101 Place City of Albany, NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition 11N )(., Place of Disposition P/; R- yr e_t,,) C✓u-win"fe t 1/ v4
w (address)
w
U)
cc (section) (lot number) (grave number)
0
Z" Name of Sexton or Person in Charge of Premises +'' b�r 8 Sr
W (please print) w
Signature Title
(over)
DOH-1555 (02/2004)