Shaughnessy, Michael . • 4 ; 3L3
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Michael G.Shaughnessy Male
Date of Death Age If Veteran of U.S. Armed Forces,
04/18/2018 77 Years War or Dates
1-:- Place of Death Hospital, Institution or
WCity, Town or Village Glens Falls Street Address Glens Falls Hospital
p Manner of Death X❑Natural Cause 0 Accident 0 Homicide ElSuicide Undetermined Pending
W Circumstances Investigation
1.iw Medical Certifier Name Title
Q William Cleaver MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 194
❑Burial Date Cemetery or Crematory
04/19/2018 Pine View Crematory
❑Entombment Address
®Cremation Queensbury Town, New York
Date Place Removed
Z❑Removal and/or Held
and/or Address
I-- Address
V) _
0 Date Point of
cil El Transportation Shipment
a by Common Destination
Carrier
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
1- Remains are Shipped, If Other than Above
2 Address
Ce
w
a' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 04/18/2018 Registrar of Vital Statistics Robert Curtis(EfectronicaltySigned)
(signature)
District Number 5601 Place Glens Falls, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
w ,.
Date of Disposition 111111Ig Place of Disposition r.IL/ ,.y.t}t_
(address)
111
Cd (section) /Lp_
(lot number) (grave number)
aName of Sexton or Person in Charge of Premises "`tt
(p/ ase print)
W al
Signature Title ilk"tR -
(over)
DOH-1555 (02/2004)