Schaefer, William L .14 -g- Zbi-
NEW YORK STATE DEPARTMENT OF HEA
LTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Wiliam L.Schaefer Male
Date of Death Age If Veteran of U.S.Armed Forces,
03/18/2022 76 Years War or Dates
s_ Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address The Pines At Glens Falls Center For Nursing&Rehabilitation
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p• Manner of Death El Natural Cause Accident Homicide Suicide ❑Undetermined ❑Pending
C.) Circumstances Investigation
W Medical Certifier Name Title
G Courtney Diamond NP
Address
170 Warren St,Glens Falls,New York 12801
DeaBth Certificate Filed �y Of Glens Falls District Number Register Number
City,Town or Village 5601 176
Burial Date Cemetery,Crematory or Facility Name
03/24/2022 Pine View Crematory
Entombment Address
Cremation Queensbuty Town,New York
nDonation
ZDRemoval Date Place Removed
and/or and/or Held
pN Hold Address
0
CL Date Point of
U)ElTransportation
CI Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
ElReinterment 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
1— Remains are Shipped,If Other than Above
_• Address
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W
n' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 03/24/2022 Registrar of Vital Statistics Alvan Nan(EYectmrriccay,Stimea)
(signature)
District Number 5601 Place City Of Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
IZfey____
—
Z Date of Disposition 75I Z'� Place of Disposition
F.y.._
W
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CC (section) (lot number) (grave number)
gName of Sexton or Person in Charge o remises ! to f kL 1 4)if
Z (ple se print)
W Signature Title 4 7/69A et
DOH 1555(o7/i8)p 1 of 2
•- F 3
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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#