Schlake, William Joseph � 03 !
NEW YORK STATE DEPARTMENT OF HEALTH rial - Transit Permit
Bureau of Vital Records Bu
Name First Middle Last Sex
William Joseph Schlake Male
Date of Death Age If Veteran of U.S.Armed Forces,
12/24/2022 85 Years War or Dates Unknown
F.. Place of Death Hospital,Institution or
Z City,Town or Village Queensbury Town Street Address 34 Willowbrook Road APT 213,Queensbury Town,New York 12804
IJJ
pManner of Death ❑X Natural Cause Accident Homicide ESuicide Undetermined El Pending
Circumstances Investigation
0 Medical Certifier Name Title
Paul Filion MD
Address
3 Irongate Center,Glens Falls,New York 12801
Death Certificate Filed Town Of Queensbury District Number Register Number
City,Town or Village 5657 193
Burial Date Cemetery,Crematory or Facility Name
12/28/2022 Pine View Crematory
Entombment Address
EiCremation Queensbury Town,New York
Donation
❑Removal Date Place Removed
— and/or and/or Held
N Hold Address
0
d Date Point of
tl)OTransportation
by Common Shipment
Carrier Destination
EDisinterment 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
1— Remains are Shipped,If Other than Above
g Address
LC
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/27/2022 Registrar of Vital Statistics Caroline 2fifiegardf Bar6er(E(ectronica((y Signed)
(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:
I— 1
W Date of Disposition /z-Zg zort f lace of Disposition � �}(2 ,G C
2 (address)
Ui
CC (section) i (lot number) i (grave number)
gName of Sexton or Person in Charge of Premise 4 l� ��1�1®✓� j number),
Z / (please print)
W Signature .J 2 /4(1' Title -e-`
DOH-1555(o7/18)p t of 2
y
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#_