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Schmulbach, Martha NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Martha Schmulbach Female Date of Death Age If Veteran of U.S.Armed Forces, 03/18/2021 95 Years War or Dates Place of Death Hospital,Institution or Z City,Town or Village Glens Falls Street Address Glens Falls Hospital 111 Undetermined Pending W Manner of Death �Natural Cause �Accident Homicide �Suicide V Circumstances Investigation Medical Certifier Name Title G Kasandra Frasier PA Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Glens Falls 5601 152 Burial Date Cemetery,Crematory or Facility Name 03/19/2021 Pine View Crematory ElEntombment Address Cremation Queensbury Town,New York Donation Z Removal Date Place Removed and/or and/or Held F— Hold Address 0 a. Date Point of (I) 11 Transportation Shipment p by Common Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596 Address 407 Bay Rd,Queensbury,New York 12804 Name of Funeral Firm Making Disposition or to Whom (- Remains are Shipped,If Other than Above 2 Address CC Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 03/19/2021 Registrar of Vital Statistics Ro6ertj?rr�rew Curtis(tE/aronicall:y Signe,a9 (signature) District Number 5601 Place Glens Falls, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z 111 Date of Disposition ?7—.2©�p2 ( Place of Disposition P;',�� jJ�eK,t (�!Y7yttiy� (address) W N Q (section) (lot number) (grave number) E. 0 Name of Sexton or Person in Charge of Premi s /�l A/��°^'+G' �'6r Z / (please print) W o Signature a / . / Title 0e-e� DOH-1555(07/18)p l of 2 Public Health Law Sec. 4145(2b) 014651 Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#