Schempp, Elaine NEW YORK STATE DEPARTMENT OF HEALTH' 4 i 611 .
Vital Records Section Burial - Tranit Permit
r Name First Middle Last Sex
Elaine Schempp Female
ti Date of Death Age If Veteran of U.S. Armed Forces,
4 September 21, 2015 93 War or Dates
Place of Death Hospital, Institution or
City, Town or Village Queensbury Street Address The Stanton Nusing and Rehabilitation
Manner of Death X❑ Natural Cause ❑ Accident ❑ Homicide ❑ Suicide n Undetermined ri❑ Pending
Circumstances Investigation
Medical Certifier Name Title CLZ�ne Zt 7
Address
n , 152 S h erm canAve- -(e,riS-Pd S , N y /28v
Death ificate Filed ict umber Re,g umber
City, own r Village Queensbury ) J
❑Burial Date Cemetery or Crematory
September 23, 2015 Pine View Crematory
❑Entombment Address
a ®Cremation Quaker Road Queensbury,NY 12804
> t Date Place Removed
❑ Removal and/or Held
and/or Address
Hold
IDate Point of
=t I I Transportation Shipment
by Common Destination
• Carrier
*40
Disinterment Date Cemetery Address
t .-< Date CemeteryAddress
gzoga❑ Reinterment
T Permit Issued to Registration Number
Eb
.r Name of Funeral Home M.B. Kilmer Funeral Home-SGF 01078
Address
136 Main Street, South Glens Falls NY 12803
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
- Address
Permission is hereb granted to dispose of the human rem s descA'bed vg as indicated.
`• ' Date Issued C 13'otc' ins
of Vital Statistics C-. �' �1' -._._
, (signature)
District Numbe S- k-Th Place 1 d , : (:)._( a
4.!._,
xv2„;
e I certify that the remains of the decedent identified above were disposed of in accor with this permit on:
R Date of Disposition 09/23/2015 Place of Disposition Quaker Road Queensbury,NY 12804
• ." (address)
t > (section) (lot number) (grave number)
Name of Sexton or Person in Charge of Premises hr��,f Stet
(pl ase print)
• Signature di ,4- Title &em it
(over)
DOH-1555 (02/2004)