Shufeld, Teresa J 11 , I/ 5-7c
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Teresa J Shufelt Female
Date of Death Age If Veteran of U.S.Armed Forces,
11/08/2021 79 Years War or Dates
�.., Place of Death Hospital,Institution or
Z City,Town or Village Troy Street Address Samaritan Hospital
LU
,p Manner of Death Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined Pending
VCircumstances Investigation
W Medical Certifier Name Title
Amelia Ciccarelli NP
Address
2215 Burdett Ave,Troy,New York 12180
Death Certificate Filed District Number Register Number
City,Town or Village Troy 4102 606
▪Burial Date Cemetery,Crematory or Facility Name
11/10/2021 Pine View Cemetery and Crematorium
Entombment Address
❑X Cremation Queensbury Town,New York
❑Donation
oRemoval Date Place Removed
and/or and/or Held
N Hold Address
0
Q. Date Point of •
co ❑Transportation
El by Common Shipment
Carrier Destination
❑Disinterment
Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Edward L Kelly Funeral Home 00519
Address
PO Box 548,Schroon Lake,New York 12870
Name of Funeral Firm Making Disposition or to Whom
E— Remains are Shipped,If Other than Above
E Address
CC
Iii
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11/10/2021 Registrar of Vital Statistics lfeatlrerL.Wulni°gkctronicallySigned)
(signature)
District Number 4102 Place Troy, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition ill 11114 Place of Dispositionti _ C241 fi—_
2 (address)
W
N
CC (section) 7Allotnumtr)., (` (grave number)
Name of Sexton or Person in Charge of isesI ► JL`^�.11�
(plea print)
Z //
W Signature Title li
DOH-1555(07/18)p t of 2
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#