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Schenk, Madeline M. NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Madaline Marie Schenk Female Date of Death Age If Veteran of U.S.Armed Forces, 03/02/2021 98 Years War or Dates H Place of Death Hospital,Institution or Z City,Town or Village Queensbury Town Street Address 304 Big Boom Road,Queensbury Town,New York 12804 IIJ 1110 Manner of Death ©Natural Cause ❑Accident 0 Homicide El Suicide ❑Undetermined Pending Circumstances Investigation Ili1 Medical Certifier Name Title CI Sharon Shannon NP Address 9 Carey Road,Queensbury Town,New York 12804 Death Certificate Filed District Number Register Number City,Town or Village Queensbury 5657 62 ©Burial Date Cemetery,Crematory or Facility Name 03/08/2021 Pine View Cemetery ❑Entombment Address ElCremation Queensbury Town,New York ❑Donation Z Removal Date Place Removed and/or and/or Held t- Hold Address N 0 a. Date Point of Cl) ❑Transportation p' by Common Shipment Carrier Destination ElDisinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home Inc 00281 Address 68 Main Street,P.O.Box 67,Hudson Falls,New York 12839 Name of Funeral Firm Making Disposition or to Whom (. Remains are Shipped,If Other than Above 5 Address CC a' Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 03/05/2021 Registrar of Vital Statistics Caroline xldegarrfe Barber(ECectronica1Ty Signed) (signature) District Number 5657 Place Queensbury, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: I— Z Date of Disposition 3/5/2 0 21 Place of Disposition 21 Quaker Rd. Queensbury, Ny 12804 tu 2 (address) Lii S & I Lot1 44 Sec. 2 3 r (section) (lot number) (grave number) 8 Name of Sexton or erson in Charge of Premises Connie Goedert Z (please print) W Signature Title Superintendent DOH-1555(07/18)p 1 of 2 Public Health Law Sec.4145(2b) Receipt 012846 Human remains of ' '\.- .., , , -- . delivered on - - - , 20 ) .., jo: - -- ,-- Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#41 7'2, Z SCHENK NAME Madeline M. Schenk Age: 98 Lot Owner: Max & Madeline Schenk Lot#Mohican sec A lot 63 Grave# 3 Case: Concrete Died: 3/2/2 0 21 Interred:3/8/2 0 21 Funeral Home: Carleton FH Cemetery: Pine View