Shaner, Jean NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Q R Name First Middle Last Sex
Jean Shay Shaner Female
Date of Death Age If Veteran of U.S. Armed Forces,
. September 1, 2016�f:r 98 War or Dates
t, ; Place of Death Hospital, Institution or
City, Town or Village Queensbury Street Address Stanton Nursing& Rehab Centre
- Manner of Death 0 Natural Cause ❑Accident ❑Homicide ❑Suicide n Undetermined n Pending
Circumstances Investigation
Medical Certifier Name Title
Bernardo Villijuan,MD
Address
ra Glens Falls,NY
`"r Death 'ficate Filed District NumberRegister Number
A Cit , Town Village Queensbury, NY 5657 I dy
®Bunat Date Cemetery or Crematory
❑Entombment September 6, 2016 Pine View Cemetery
Address
❑Cremation Quaker Road Queensbury, Queensbury,NY 12804
Date Place Removed
Z
I Removal and/or Held
and/or Address
H Hold
CO
0 Date Point of
Nn Transportation Shipment
'p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
0
Permit Issued to Registration Number
til Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
'f- Address
%." 407 Bay Road,Queensbury,NY 12804
Name of Funeral Firm Making Disposition or to Whom
iRemains are Shipped, If Other than Above
Address
, Permission is hereby granted to dispose of the human remains describe above as indicated.
Date Issue 1 L4.1,f:40\ (p Registrar of Vital Statistics . q fLc�.._
_ (signature)
District Number. 'l Place d4 S �0'
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
LLI Date of Disposition 9/6/201 6 Place of Disposition Pine View CG,mPi-pry, upencbury, NY
(address)Q
W
�
Hudson_ 1 6C 2
(section) (lot number) (grave number)
pName of Sex or Person in Charge of Premises Connie L. Goedert
W (please print)
Signature Aftc.6, .12C(24c Title Cemetery Superintendent
(over)
DOH-1555(02/2004)