Schmeer, Victor ft
NEW YORK STATE DEPARTMENT OF HEALTH ZZ
Vital Records Section r • 1 Burial - Transit Permit
Name First Middle Last Sex
Victor Davis Schmeer Male
Date of Death Age If Veteran of U.S. Armed Forces,
April 26,2012 71 War or Dates N/A
F- Place of Death Hospital, Institution MC-Lake Placid, Church Street,Lake
Z City, Town or Village Town Of North Elba Street Address Placid.NY 12946
WW Manner of Death
X Natural Cause Accident I I Homicide Suicide Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
Ci C.Francis Varga,MD
Address
,P.O.Box 768,Lake Placid,NY 12946
Death Certificate Filed Lake Placid, Town of District Number - I Register Number
City, Town or Village North Elba 1523 � 3k
❑Burial Date Cemetery or Crematory , N
April 30,2012 Pine View Crematory
❑Entombment Address
❑x Cremation 21 Quaker Rd., Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
O and/or Address
H Hold
N
0 Date Point of
NTransportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M.B. Clark,Inc. 01075
Address
2310 Saranac Ave.,Lake Placid,NY 12946
Name of Funeral Firm Making Disposition or to Whom
I— Remains are Shipped, If Other than Above
i Address
C4
W
O. Permission is hereby granted to dispose of the human re ins d crib d above as indicated.
c /
Date Issued Apr:27-2012 Registrar of Vital Statistics 410� t �l%
( ature)
District Number 1523 Place Village of Lake Placid
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w Date of Disposition ti t y,t►, 1'•
. Place of Disposition , glom A W (address)
co
re
0 (section) (lot number) S (grave number)
p Name of Sexton or Peron in Charge f Premises f r,s}ct,�tr �,H
Z lease print)
W
Signature átpL_ Title C{{. ,i r't,
(over)
DOH-1555 (02/2004)