Shultes, Maryann 1iST_3
NEW YORK STATE DEPARTMENT OF HEALTH '� Burial - Transit Permit
Vital Records Section 74-
Name First Middle Last Sex
MaryAnn F Shultes Female
Date of Death Age If Veteran of U.S.Armed Forces,
3/17/2013 47 War or Dates
I- Place of Death Hospital, Institution
Z City ,Town or Village City of Albany or Street Address Albany Medical Center
W Manner of Death Natural Undetermined Pendin
9
W ® Cause ❑ Accident ❑ Homicide ❑ Suicide
❑ Circumstances ❑ Investigation
U Medical Certifier Name Title
C3 Erin Morine DO
Address
43 New Scotland Avenue Albany, NY 12208
Death Certificate Filed District Number Register Number
City,Town or Village City of Albany 101 571
Date Cemetery or Crematory
LI Burial 3/20/2013 Pineview Crematory
❑ Entombment Address
® Cremation Queensbury, NY 'aODil
Date Place Removed
Z Removal and/or Held
O ❑ and/or Address
I:: Hold
U)
Q, Date Point of
CL Transportation Shipment
U) ❑ By Common
Carrier Destination
❑ Disinterment
Date Cemetery Address
El Reinterment
Cemetery Address
Reinterment
Permit Issued To Registration Number
Name of Funeral Home Singleton, Sullivan, Potter Funeral Home 01596
Address
407 Bay Rd Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
• Address
ft
W'
12 Permission is hereby granted to dispose of the human remains described above as indicated.
Date 3/20/2013 d.-G,,,,;.., C _
Issued Registrar of Vital Statistics
(signature) SW
District Number 101 Place City of Albany, NY t GI- --o 6
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition 3) 13 Place of Disposition A N 12 V fir^,✓ LA<Gn d4 h
w (address)
w
co
re (section) (lot number) (grave number)
O
Z• Name of Sexton r Person ' harge of Premises ��`]� OvJ /fry
W (please print)
Signature :,.. Title `-72P.47 A-1 it f b 7.
(over)
DOH-1555 (02/2004)