Metthe, Shirley L. NEW YORK STATE DEPARTMENT OF HEALTH BUrlal - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
ShirleyL.Metthe Female
Date of Death Age If Veteran of U.S.Armed Forces,
12/02/2019 95 Years War or Dates
Place of Death Hospital,Institution or
WCity,Town or Village Schroon Town Street Address 40 Continental Drive, Schroon Town, New York 12870
p Manner of Death ®Natural Cause Accident Homicide Suicide Undetermined Pending
UCircumstances Investigation
0 Medical Certifier Name Title
Mary Stein NP
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed District Number Register Number
City,Town or Viltage Schroon Lake 1563 04
Burial Date Cemetery,Crematory or Facility Name
12/03/2019 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
0 Removal Date Place Removed
and/or and/or Held
H N Hold Address
O
d Date Point of
to Transportation
p by Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Edward L Kelly Funeral Home 00519
Address
PO Box 548,Schroon Lake,New York 12870
Name of Funeral Firm Making Disposition or to Whom
�— Remains are Shipped,If Other than Above
Address
Q
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/03/2019 Registrar of Vital Statistics (Patricia Savarie(ECectronicadySWned)
(signature/
District Number 1563 Place Schroon Lake, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
II—
Z Date of Disposition Place of Disposition ,,�
W
2 (address)
W
N Q (section) (lot number) (grave number)
O Name of Sexton or Person in Charge of Premises rl't
0 Z (p! print)
W Signature Title ftwo ly—rok
DOH-i555(07/18)p 1 of 2
Public Health Law Sec-. 414.,5(2b) 013123
Receipt
Human remains of delivered on , 20
f
Pine View Cemetery Represe ing the funeral home named on burial permit
Official Funeral/Directors Reg.or License i