Schroeck, Stephen f s IF
NEW YORK STATE DEPARTMENT OF HEALTH # `1bo
Vital Records Section "'...,`'— Burial - Transit Permit
Name First Middle Last Sex
Stephen A. Schroeck Male
Date of Death Age If Veteran of U.S. Armed Forces,
October 18, 2016 67 War or Dates _
Place of Death Hospital;Institution or
: City, Town or Village Queensbury Street Address 12 Crad Tree Lane
Manner of Death A Natural Cause Accident n Homicide ❑Suicide Undetermined n Pending
Circumstances Investigation
Medical Certifier Name Title
Robert Beaty
Address
100 Broad Street,Glens Falls,NY 12801
;;{: Death Certificate Filed District Number Register Number
: City, Town or Village Queensbury 5657 %
❑Burial Date Cemetery or Crematory
II Entombment October 20, 2016 Pine View Crematory
Address
❑x Cremation Quaker Road, Queensbury,NY 12804
Date Place Removed
Z ❑Removal and/or Held
and/or Address
H Hold
V)
O Date Point of
lik n Transportation Shipment
a by Common Destination
Carrier
n Disinterment Date Cemetery Address
n Renterment Date Cemetery Address
4 Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
i Address
Jai 53 Quaker Road, Queensbury, NY 12804
Y
:l Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
fV,
Permission is hereby granted to dispose of the human Ins 'bid o a i•icated.
'.{: Date Issued lee-- 14 Registrar of Vital Statistics " AA,,1 ►
(sign•14*_)
V District Number Place
f�f.: 5657 Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition Iolzq lib Place of Disposition enh lrv./ Cttmu7jOriw.,
W (address)
CO
re (section) ��(lot number) (grave number)
QName of Sexton or Person in Charge of Premises t,sb 5e ii�►
Z / (pledse print)
W
Signature """j. /// Title GCTli i L
(over)
DOH-1555(02/2004)