Shaw, Agnes -kJNEW YORK STATE DEPARTMENT OF HEALTH '
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Agnes Dolores Shaw Female
Date of Death Age If Veteran of U.S. Armed Forces,
09/19/2018 95 Years War or Dates
Place of Death Hospital, Institution or
City, Town or Village Queensbury Town Street Address Warren Center for Rehabilitation and Nursing
Manner of Death gin Natural Cause Accident El Homicide El Suicide Undetermined ri Pending
Circumstances Investigation
Medical Certifier Name Title
Roslyn Socolof MD
Address
42 Gurney Ln,Queensbury Town,New York 12804
Death Certificate Filed District Number Register Number
City, Town or Village Queensbury 5657 132
Date Cemetery
El Burial or Crematory
09/24/2018 Pine View Crematory
❑Entombment Address
giCremation Queensbury Town, New York
Date Place Removed
El Removal
and/or Held
and/or Address
Hold
Date Point of
Q Transportation Shipment
by Common Destination
Carrier
El Disinterment Date Cemetery Address
El Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D Baker Funeral Home 01130
Address
11 Lafayette St,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 09/24/2018 Registrar of Vital Statistics Caroline 2f(l3arber( lectronicaulySigned)
(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:
Date of Disposition ThS tI? Place of Disposition , ,
(address)
(section) lot number) (grave number)
Name of Sexton or Person in Charge of Premiss /[i SPnn/d'
� (p/ se print)
Signature !� fc' Title (RjAa9 VQ
(over)
DOH-1555(02/2004)