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Schult, Wendly NEW YORK STATE DEPARTMENT OF HEALTH 7 Vital f eco •Section Burial - Transit Permit Name First Middle Last Sex Wendyn Spaulding Schult Male PA: Date of Death Age If Veteran of U.S. Armed Forces, January 3, 2016 91 War or Dates 1; Place of Death Hospital, Institution or Fli City, Town or Village Fort Edward Street Address FORT HUDSON HEALTH CARE FAC. iC Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending III; ❑ ❑ ❑ ❑ ❑ ❑ 0. Circumstances Investigation W Medical Certifier Name Title Daniel C Larson M.D., , 1 . ..E„ i n c (1 ; ) /I 14 P. Address . 9 Carey Road Queensbury, NY 12804 . Death Certificate Filed District Number Register Number =016 City, Town or Village _1j I .66 I ;j❑Burial Date Cemetery or Crematory January 5, 2016 Pine View Crematorium ❑Entombment Address 7*©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed z❑ Removal and/or Held and/or Address .- Hold 07 Date Point of ❑Transportation Shipment 0; by Common Destination d Carrier Date Cemetery Address ❑ Disinterment Date Cemetery Address ❑ Reinterment Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home, Inc. 00281 Address Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839 Name of Funeral Firm Making Disposition or to Whom 1- Remains are Shipped, If Other than Above 2. Address Ce w Permission is hereby granted to dispose of the human e i. s described ay re as i dicated. Date Issued j 16b, Registrar of Vital Statistics _ V (signature) District Number 6n Place IO-U.Y7... Z. LU I I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: W Date of Disposition 01/05/2016 Place of Disposition Quaker Road Queensbury,NY 1 804 2 (address) tltco Ifs (section) (lot number) (grave number) 0 a Name of Sexton or P rson i Charge of Premises <\ r.,, l;ca,et 4-44c.z-Le. Z ,i (please print) W: Signature Title (over) DOH-1555 (02/2004)