Scheideler, Joan NEW YORK STATE DEPARTMENT OF HEALTH. . '' # (2Z G
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Joan Stephanie Scheideler Female
Date of Death Ag
e If Veteran of U.S. Armed Forces,
'/ October 3,2014 90 War or Dates n/a
"' Place of Death Hospital, Institution or
i City, Town or Village Fort Edward Street Address Fort Hudson Nursing Home
„% Manner of Death 12. Natural Cause ❑Accident n Homicide ❑Suicide 1-1 Undetermined C Pending
4 Circumstances Investigation
Medical Certifier Name Title
j Philip Gara,MD
Address
41 Fort Edward,NY
Death Certificate Filed District Number Registe Number
,,,�
1
City, Town or Village Fort Edward,NY 5755
❑Burial Date Cemetery or Crematory
❑Entombment October 6,2014 Pine View Crematorium
Address
®Cremation Quaker Road, Queensbury,NY 12804
Date Place Removed
Z ❑Removal and/or Held
and/or Address
H Hold
N
0 Date Point of
N ❑Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
rg Permit Issued to Registration Number
f
Name of Funeral Home Re l an Denn Stafford Funeral Home 01443
. Address
ff•
53 Quaker Road, Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
s Remains are Shipped, If Other than Above
izl
vI Address
, ; Permission is he by ra ted to dispose of the human ins described bove s indicated.
Date Issued /� �p Registrar of Vital Statisti Q® .d
_,7
`, (signatGre)
r
'District Number 5755 Place Fort Edward,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition io AI N Place of Disposition -0mUtr,, Cr;.1tar
_
2 (address)
W
X .;i
_y, (section) A (lot number) c (grave number)
p Name of Sexton or person irti`charge of Premises I L olnl '
W (plse print)
Title CRF_WI
Signature • . : i
(over)
DOH-1555(02/2004) •'