Schmidt, Eileen M NEW YORK STATE DEPARTMENT OF H EALTH @ Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Eileen M.Schmidt Female
Date of Death Age If Veteran of U.S.Armed Forces,
09/19/2022 75 Years War or Dates
H Place of Death Hospital,Institution or
Z City,Town or Village Queensbury Town Street Address 180 Robert Gardens N 8,Queensbury Town,New York 12804
EMannerof Death Ei Natural Cause Accident El Homicide ESuicide ❑Undetermined ❑Pending
W
U Circumstances Investigation
WW Medical Certifier Name Title
CI Jennifer Stratton MD
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed Town Of Queensbury District Number Register Number
Cit ,Town or Village 5657 134
X Burial Date Cemetery,Crematory or Facility Name
09/23/2022 Pine View Cemetery
Entombment Address
❑Cremation Queensbury Town,New York
Donation
gRemoval Date Place Removed
F and/or and/or Held
N Hold Address
0
IL Date Point of
CO Dansportation
p by Common Shipment
Carrier Destination
Disinterment
Date Cemetery Address
El
Re interment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
1.- Remains are Shipped,If Other than Above
a Address
IX
W
n' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 09/22/2022 Registrar of Vital Statistics Camlixs?fi�gar4*Batfier(Efectmttic StgtudJ
(signature)
District Number 5657 Place Town Of Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition q a3 .a, Place of Disposition ,-2/ Ot ,akeR R6 7"),reefs J r V
/ /t//ano1
2 (address) !!
W 1it<-/.1`( h ) ty i
U)CC section) (lot number) (grave number/
SName of Sexton or Person in Charge of Premises _�/1n (?i e -)r-,-,-- T
Z (please Fife /l
W Signature Title cor.. /0 fit`
DOH 1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) 012944
Receipt
Human remains of Fr, e ���,�� delivered on , 20(0
SIS/1
e View Cemetery Representing the funeral home n n b er
•
fficial Funeral Directors Reg.or License
SCHMIDT
NAME Eileen Schmidt Age: 75
Lot Owner: Eileen Schmidt
Lot# Horicon 40 H Grave# 1
Case: Concrete
Died: 9 . 1 9_2 2 Interred:9.2 3.2 2
Funeral Home: Regan Denny Stafford
Cemetery: Pine View