Shields, Beth NEW YORK STATE DEPARTMENT OF HEALTH SI IP,
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Beth Anne Shields Female
Date of Death Age If Veteran of U.S. Armed Forces,
05127/2018 61 Years War or Dates
Place of Death Hospital, Institution or
' City, Town or Village Queensbury Town Street Address Warren Center for Rehabilitation and Nursing
so Manner of Death j Natural Cause Accident ❑Homicide Suicide ❑Undetermined ri Pending
Circumstances Investigation
Medical Certifier Name Title
Roslyn Socoiof D
Address
42 Gurney Ln,Queensbury Town,New York 12804
'.: Death Certificate Filed District Number Register Number
City, Town or Village Queensbury 5657 66
®Burial Date Cemetery or Crematory
06104/2018 Pine View Crematorium
❑Entombment Address
Cremation Queensbury Town, New York
Date Place Removed
':. ❑Removal and/or Held
and/or Address
Hold
71
• Date Point of
6 ❑Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
M Permit Issued to Registration Number
3 ':`, Name of Funeral Home Carleton Funeral Home Inc 00281
Address
68 Main Stpo Box 67,Hudson Falls,New York 12839
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
d_.
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 05/30/2018 Registrar of Vital Statistics Caroline XBarser(EfectroniadrySigned)
(signature)
District Number 5657 Place Queensbury, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
III! Date of Disposition (el (I S Place of Disposition f�L ..��..
(address)
0
e (section) (jy+tnumber). (grave number)
d Name of Sexton or Person in Charge of Premises lA/
(pies a print)
Signature Title Ciwm r2
(over)
DOH-1555 (02/2004)