Schaffer, John Richard Sr. LF
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
John Richard Schaffer Sr. Male
Date of Death Age If Veteran of U.S.Armed Forces,
10/11/2023 84 Years War or Dates 1958-61
Place of Death Hospital,Institution or
Z City,Town or Village Moreau Town Street Address 1 Jamaica Avenue, Moreau Town,New York 12803
111
p Manner of Death ❑X Natural Cause []Accident []Homicide El Suicide []Undetermined ❑Pending
W I ('Circumstances Investigation
U
W Medical Certifier Name Title
Lynn Keil PA
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed Town Of Moreau District Number Register Number
City,Town or Village 4562 56
[ ]Burial Date Cemetery,Crematory or Facility Name
10/13/2023 Pine View Crematory
Address
[]Cremation Queensbury Town,New York
Donation
ZO❑Removal Date Place Removed
and/or and/or Held
- Hold Address
0
Date Point of
Cl)IIITransportation
by Common Shipment
Carrier Destination
III
Disinterment
Date Cemetery Address
[]Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M B Kilmer Funeral Home-South Glens Falls 01078
Address
136 Main St,S Glens Falls,New York 12803
Name of Funeral Firm Making Disposition or to Whom
f.. Remains are Shipped,If Other than Above
Address
CC
W
0-
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 10/13/2023 Registrar of Vital Statistics <drendaSYutter('E/ctrouical1 Signed)
(signature)
District Number 4562 Place Town Of Moreau
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition 0—/7 ?'Z.3 Place of Disposition e, e v;et,) epettia^f
•9
2 (address)
W
U)
CC (section) (lott1number (grave number)
0 Name of Sexton or Person in Charge of remise ke.470� tt DQ
Z I—(please print)
111 Signature {J�i,'f�Title Q�
DOH-1555(o7/18)p i 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#