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Dagert, Shirley NEW YORK STATE DEPARTMENT OF HE 4:\ i J" Vital Records Section Burial Transit Permit Name First Last Sex Shirley � 1 ert Female Date of Death Age eteran of U. Armed Forces, November 21, 2018 82 War orate wPlace of Death Hospit, nstitution or City, Town or Village Hudson Falls "`. ...---. Street Address 20 Spruce St. 0 Manner of Death Natural Cause ElAccident ElHomicide ElSuicide ❑ Undetermined ❑ Pending Circumstances Investigation CI Medical Certifier Name Title Darci Gaiotti-Grubbs, Dr. Address 102 Park Street Glens Falls, NY 12801 Death Certificate Filed District Number Register Number = City, Town or Village _�7a b 2 5 -,❑Burial Date Cemetery or Crematory November 26, 2018 Pine Vew Crematorium ❑Entombment Address ©Cremation Queensbury,NY 12804 Date Place Removed z ❑ Removal and/or Held and/or Address N Hold Pine View Crematorium t Date Point of a. ❑Transportation Shipment 0 by Common Destination p Carrier Date Cemetery Address El Disinterment [II 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 F Remains are Shipped, If Other than Above E. Address W' Permission is hereby granted to dispose of the human remain escribed above as indicated. -6 r ,;'a/! Registrar of Vital Statistics Date Issued i! :�' 9� � � Ci__K -2-L_____ (signature) District Number 7a‘„ Place N:fj o--- - t� Y` CMG . I certify that the remains of the decedent identified abo were disposed of in accordance with this permit on: w Date of Disposition 11/26/2018 Place of Disposition Queensbury,NY 12804 D ,irk, 1J�tt,,, c�'vr,,,,,kr.y (address) LU CO' IX (section) (lot number) (grave number) a' Name of Sexton or Person in Charge of Premises Tz ii'.c y S ,t i;ri,C (please print) W Signature Title Crtm;4nr (over) DOH-1555 (02/2004) P