Schmeelke, Helmut NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Helmut E. Schmeelke Male
« Date of Death Age If Veteran of U.S. Armed Forces,
4/14/13 72 War or Dates yes 1959-1962
Place of Death Hospital, Institution or
City, Town or Village Moreau Street Address 220 Old Saratoga Road
lii
o Manner of Death®Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined El Pending
W. Circumstances Investigation
ill Medical Certifier Name Title
0. John E. Lukaszewicz M.D.
Address
84 BRoad Street, Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village Town of Moreau 4562 9
❑Burial Date Cemetery or Crematory
4/16/2013 . Pine View Crematory
r❑Entombment Address
iliiiiii OCremation Queensbury, NY 12804
Date Place Removed
2 ❑Removal and/or Held
and/or Address
F_ Hold
to
0 Date Point of
Transportation Shipment
ES by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
01
" Permit Issued to Registration Number
itiii Name of Funeral Home Maynard D. Baker 01130
ieii Address
11 Lafayette Street, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
;'; Address
iI
Permission is hereby granted to dispose of the human remains described 9,.
abov�a�ated.
Date Issued 4/16/13 Registrar of Vital Statistics 76e...4.l4-4.4..t__ 7,'J(signature)
District Number 4562 Place 61 Hudson Street, South Glens Falls, NY 12803
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
10
ILI { �
Date of Disposition t-11i3 Place of Disposition 1, rz Creyvadrii^r-.
2 (address)
Ili
Cl) (section) 4 (lot number) (grave number)
ci Name of Sexton or Pers n in Charge o Premises irrJ- , hiJtt
Z ( lease print)
Signature ` Title Cgetti lira,
(over)
DOH-1555 (02/2004)