Austin, Shirley NSW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Shirley Elizabeth Austin Female
Ai Date of Death Age If Veteran of U.S. Armed Forces,
NI
April 30, 2017 87 War or Dates
Place of Death Hospital, Institution or
1,11
City, Town or Village South Glens Falls Street Address 26 Terry Dr.
CI Manner of Death 0 Natural Cause ❑ Accident ❑ Homicide ❑ Suicide 0 Undetermined Pending
Circumstances Investigation
U.I. Medical Certifier Name Title
CC Paul R Filion, M.D. Dr.
Address
Three Iron Gate Center Glens Falls, NY 12801
i Death Certificate Filed District 7ftr_, Rego ._J umber
City, Town or Village � oc
®Burial Date Cemetery or Crematory
,c May 3, 2017 Pine View Cemetery
❑Entombment Address
❑Cremation Quaker Rd. Queensbury,NY 12804
Date Place Removed
Removal and/or Held
and/or Address
Hold Pine View Cemetery
Date Point of
Transportation Shipment
by Common Destination
- Carrier
i. Date Cemetery Address
❑ Disinterment
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
.- Address
tX.
't
EL,' Permission is hereby ranted to dispose of the human rema' ibed a, • e indicated.
Date Issued S 0/ Registrar of Vital Statistics I {,u
/1 s ignatu
District Number
,.� � �— Place �� ,aids kdt �QGu, A/ id ��
Al I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 05/03/2017 Place of Disposition Quaker Rd. Queensbury,NY 12804
, _ (address)
I (section) (lot number) (grave number)
Name of Sex,on or Person in Charge of Premises
.' (please print)
W: Signature K-G�-I.t `�- Titl 1 S.,_..t
.La-AC—
(over)
DOH-1555 (02/2004)