Dean, Shawn NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Shawn Matthew Dean Male
Date of Death Age If Veteran of U.S. Armed Forces,
August 21, 2016 30 War or Dates
I Place of Death Hospital, Institution or
W City, Town or Village Whitehall Street Address 16 Champlain Avenue
W Manner of Death X❑Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
0
W Medical Certifier Name Title
in
Address
Death Certificate Filed District Number Register Number q
City, Town or yillage h i- ,h a 11 5 70
®Burial Date Cemetery or Crematory
August 29, 2016 ST. ALPHONSUS CEMETERY
❑Entombment Address
❑Cremation Town of Queensbury,NY
Date Place Removed
z ❑ Removal and/or Held
0and/or Address
E Hold ST. ALPHONSUS CEMETERY
Date Point of
a. ❑Transportation Shipment
co by Common Destination
f Carrier
nDisinterment Date Cemetery Address
❑ 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
I— Remains are Shipped, If Other than Above
Z' Address
IX
W'
E" Permission is hereby granted to dispose of the human remains described above a indicated.
Date Issued S'a`-�--Zoi(p Registrar of Vital Statistics , p /
(signature)
District Number J-jag Place \f c N L
1
F— I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 08/29/2016 Place of Disposition Town of Queensbury,NY
al� ss)w 6 2
co
ix (section) //oArk_
Ilgt number) (grave(grave number)
0 Name of Sexton o Person in Charge of Premises
Z (please print)
1L Signature / Title
(over)
DOH-1555 (02/2004)