Shaw, Kevin y hilly
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Kevin Allen Shaw Male
Date of Death Age If Veteran of U.S. Armed Forces,
12/13/2018 58 Years War or Dates
Place of Death Hospital, Institution or
City, Town or Village Granville Village Street Address Indian River Rehabilitation And Nursing Center
Manner of Death Q Natural Cause Accident El Homicide Suicide El Undetermined n Pending
Circumstances Investigation
wt! Medical Certifier Name Title
Leonard Gelman MD
Address
17 Madison St,Granville Village,New York 12832
Death Certificate Filed District Number Register Number
City, Town or Village Granville Village 5725 53
El Burial Date Cemetery or Crematory
12/17/2018 Pine View Crematory
[]Entombment Address
'®Cremation oueetsburylbwn, New York
Date Place Removed
d[Removal and/or Held
and/or Address
tHold
Q Date Point of
aQ Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Renterment Date Cemetery Address
Permit issued to Registration Number
Name of Funeral Home M B Kilmer Funeral Home-Fort Edward 01079
Address
82 Broadway,Fort Edward,New York 12828
Name of Funeral Firm Making Disposition or to Whom
t Remains are Shipped, If Other than Above
• Address
W
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/14/2018 Registrar of Vital Statistics Wichand iRy6erts(Ekctmnica1ySigned)
(signature)
District Number 5725 Place Granville Village, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
lsu Date of Disposition )2/I`t I IC Place of Disposition ?:,t e V,t W t Pe r^kTQ!.4l'^
(address)
w
rt. (sewn) N (lot number) (grave number)
p• Name of Sexton or Person in Charge of Premises
(Please Print)
Ul %Signature Title
(over)
DOH-1555(02/2004)