Adams, Shanon NEW YORK STATE DEPARTMENT OF HEALTH #
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Shanon D. Adams Female
Date of Death Age If Veteran of U.S. Armed Forces,
April 7, 2017 70 War or Dates n/a
Place of Death Hospital, Institution or
City, Town or Village Saratoga Springs Street Address Saratoga Hospital
Manner of Death FX]Natural Cause [:]Accident [-�Homicide F-1 Suicide [:]Undetermined El Pending
Circumstances Investigation
Medical Certifier Name Title
Carlos A.Ares,MD
Address
211 Church Street, Saratoga Springs,New York 12866
Death Certificate Filed District Number Register Number
City, Town or Village Saratoga 4501
❑Burial Date Cemetery or Crematory
❑Entombment April 14,2017 Pine View Crematorium
Address
Cremation 51 Quaker Road, Queensbury,NY 12804
Date Place Removed
Removal and/or Held
and/or Address
Hold
0 Date Point of
& Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
F-1 Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan& Denny Funeral Home 01444
Address
94 Saratoga Avenue, South Glens Falls,NY 12803
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remain s ib-'" aboT. . dicated
Date Issued L4 1101 N- Registrar of Vital Statistics (signature)
District Number 4501 Place Saratoga Sminqn-
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
z
Lu Date of Disposition [j_qfI
2 T/ Place of Disposition (address)
W
(section) (lot number) (grave number)
0
a Name of Sexton or Person in Charge of Premises wl'i L If
z (blease print)
W
Signature Title traimitrat-
(over)
DOH-1 555(02/2004)