Schelhorn, Sally NEW YORK STATE DEPARTMENT OF HEAL-I �"
Vital Records Section Burial - Transit Permit
Name First • Middle Last Sex
Sally J. Schelhorn Female
Date of Death Age If Veteran of U.S. Armed Forces,
May 14,2012 89 War or Dates
. Place of Death Hospital, Institution or
Z: City, Town or Village Glens Falls Street Address Glens Falls Hospital
ILI
Manner of Death I Xi Natural Cause Accident Homicide Suicide Undetermined Pending
0.
Circumstances Investigation
ww Medical Certifier Name Title
13 Suzanne Rayeski
Address
3767 Main Street,Warrensburg,NY 12885
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 .220
❑Burial Date Cemetery or Crematory
Entombment May 15,2012 Pine View Crematory
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
Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Alexander-Baker Funeral Home 00035
Address
3809 Main Street,Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
# Remains are Shipped, If Other than Above
a Address
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Ull
Ea Permission is hereby granted to dispose of the human remains described above al indicated.
Date Issued 5l i 5 C/z Registrar of Vital Statistics Wn,�,� ,�
_ Y- " (signatu
District Number 5601 Place Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z !� I
iti Date of Disposition j Jp.la Place of Disposition Z'wV Cti. rim
W (address)
CO
pa' (section) /1 (1 number) (grave number)
Name of Sexton or Per on in Charge of Premises 6 It„jar �L.�. �
Z ( ease print)
W
Signature Title .,M t;0(L
VY (over)
DOH-1555 (02/2004)