Schultz, Edna It
NEW YORK STATE DEPARTMENT OF HEALTH f ' k , '
Vital Records Section Burial - Transit Permit
Name First Middle- Last Sex
Edna Ann Schultz Female
Date of Death Age If Veteran of U.S. Armed Forces,
07/13/2012 60 yearc War or Dates
lF Place of Ueath Hospital, Institution or
City, Tov1 XV. -.- Street Address
:�♦ X Glens F� Glens Falls hospital
Manner o- eat Natural Cause Accident ❑Homicide ❑Suicide ❑uncetermined ❑Pending
Circumstances Investigation
tu Medical Certifier Name Title
0
Add�e Jennifer Stratton M D
s
14 Manor Drive Queensbury, N Y 12804
Death Certificate Filed District Number Register Number
City, To CX Glens Falls 5601 328
ni❑Burial ate Cemetery or Crematory
Mil❑Entombment Address07/17/2012 Pine View Crematorium
❑Cremation Queensb"pry, NY 12804
Date Place Removed
❑Removal and/or Held
and/or Address M
Hold
0 Date Point of
fAi El Transportation Shipment
G by Common Destination
Carrier
Q Disinterment Date Cemetery Address
•
Reinterment Date Cemetery Address
lig Permit Issued to Registration Number
Name of Funeral Home Wilcox & Regan Funeral Home 01821
Address
11 Alqonkin Street Ticonderoga, N Y 14$$3
II Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
IX
fl` Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 07/16/2012 Registrar of Vital Statistics ck. LA1
(signature)
District Number Place
5601 Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
lit Date of Disposition �-11-0_ Place of Disposition 1 ,,,,,J 6 r,,,,•,
(address)
III
CC (section) p (lot nuper) (grave number)
i Name of Sexton or Person in Charge of Premises f1;t,t,� 6.4
E. 41 V (please print)
Signature . Title Ctiti-Ve:
(over)
DOH-1555 (02/2004)