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Schultz, Cassandra L if NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Cassandra L.Schultz Female Date of Death Age If Veteran of U.S.Armed Forces, 12/02/2023 32 Years War or Dates Place of Death Hospital,Institution or Z City,Town or Village Hudson Falls Village Street Address 51 Wall Street, Hudson Falls Village, New York 12839 p Manner of Death ElNatural Cause ❑Accident El Homicide nSuicide Undetermined Ea Pending 111 Circumstances IlInvestigation W Medical Certifier Name Title G Robert Lemieux Coroner Address 415 Lower Main Street,Hudson Falls Village,New York 12839 Death Certificate Filed Village Of Hudson Falls District Number Register Number City,Town or Village 5726 33 Burial Date Cemetery,Crematory or Facility Name 12/07/2023 Pine View Crematorium _Entombment Address ©Cremation Queensbury Town,New York Donation Z❑Removal Date Place Removed and/or and/or Held F- Hold Address 0 d Date Point of Cl) Transportation a- by Common Shipment Carrier Destination ElDisinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home Inc 00281 Address 68 Main Street,P.O.Box 67,Hudson Falls,New York 12839 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped,If Other than Above 5. Address CC a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 12/06/2023 Registrar of Vital Statistics Cynthia cBard n(ECectronicaCCySigned) (signature) District Number 5726 Place Village Of Hudson Falls I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z Date of Disposition lZ t14 It) Place of Disposition '7T4L-tn-GJ 6ef-A 2 (address) 0 CC (section) (lot number) cam+""^'' (grave number) Name of Sexton or Person in Charge of Premises r. L (plejase print) Signature � ' Title no4 170( DOH-1555(07/18)p 1 of 2 � of 0 .ems p 7"nt' 7 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#