Schiavone, Ann t 5-)17
NEW YORK STATE DEPARTMENT OF HEALTH P
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
'~ Ann F. Schiavone Female
06 Date of Death Age If Veteran of U.S. Armed Forces,
08/09/2016 73 War or Dates
,, Place of Death Hospital, Institution or
1•_ City,Town or Village Street Address
,�' i Manner of Death 0 Natural Cause 0 Accident El Homicide 0 Suicide Undetermined 17 Pending
Circumstances Investigation
Medical Certifier Name Title
1 John P. Stoutenburg, MD,
-
Address
102 Pa Street Glens Falls, NY 12801
N Deat ficate Filed - ' District Number 5/6Register Number
- Cit To r Village �� /7 S i t _
0Burial Date �(or Cram tory cm
❑ 08/15/2016 fl �Q (/'2".e t�iz�,�2C7/ ','' ��
ifo Entombment Address ., G
®Cremation /,-ev - / -
N Place Removed
Date
Removal and/or Held
and/or Hold Address
Date Point of
- : El Transportation Shipment
by Common Destination
Carrier _
Disinterment Date Cemetery Address
,LiVP-
ElReinterment Date Cemetery Address
Permit Issued to Registration Number
v iti Name of Funeral Home Barton-McDermott Funeral Home, Inc. 00141
Address
r', 9 Pine St/P.O. Box 455 Chestertown NY 12817
-` 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 remain described ab ve as indicated.
rifi Date Issued — t l - 1 (1�, Registrar of Vital Statistics D CL i.
(signature)_
District Number 5LbS Place L. r
•_:-7:
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 1116//4 Place of Disposition 4cOtt.i (,C f&.
(address)
`'
(section) 1 (lot number) (grave number)
Name of Sexton or Person in Charge f Premises ref
‘-x4, / 11C,..,
jge[b�
lease prinnt)��,, �,1
'� Signature Title C'�L�"�f t`�
(over)
DOH-1555 (02/2004)