Schmeelke, Beverly Viola Z 5(
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit rermit
Bureau of Vital Records
Name First Middle Last Sex
Beverly Viola Schmeelke Female
Date of Death Age If Veteran of U.S.Armed Forces,
03/22/2021 77 Years War or Dates
F Place of Death Hospital,Institution or
WCity,Town or Village Moreau Town Street Address 220 Old Saratoga Road,Moreau Town,New York 12831
p Manner of Death Natural Cause EI Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
W• Medical Certifier Name Title
C3 Patricia Ford MD
Address
445 New Kamer Road,Colonie Town,New York 12205
Death Certificate Filed District Number Register Number
City,Town or Village Moreau 4562 17
❑Burial Date Cemetery,Crematory or Facility Name
03/23/2021 Pine View Crematory
El Entombment Address
ElCremation Queensbury Town,New York
ElDonation
ElRemoval Date Place Removed
and/or and/or Held
N Hold Address
0
Q. Date Point of
Cl) Li Transportation
p by Common Shipment
Carrier Destination
El
Disinterment
Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D Baker Funeral Home 01130
Address
11 Lafayette St,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped,If Other than Above
Address
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 03/23/2021 Registrar of Vital Statistics Leeann.Yfcca6e(Ekctranicaf Signed
(signature)
District Number 4562 Place Moreau, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition 317 S Eli Place of Disposition RI_
�c�
2 (address)
W
N CC (section) ot number) (grave number)
tj
S Name of Sexton or Person in Charge of Premises IcipL 04444 tr
Z (please int)
W Signature Title 0�" 'LI"�
DOH-1555(07/18)p t of 2
Public Health Law Sec. 4145(2b) 01 6 6
Receipt
Human remains of : delivered on 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#