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Mannis, Shirley 1 IT NEW YORK STATE DEPARTMENT OF HEALTH 'r` + D cc Vital Records Section Burial - Transit Permit ? Name First Middle Last Sex 2.5 Shirley Lois Mannis Female Date of Death Age If Veteran of U.S. Armed Forces, 10/19/2018 83 Years War or Dates a Place of Death Hospital, Institution or City, Town or Village Fort Edward Town Street Address Fort Hudson Nursing Center Inc Manner of Death©Natural Cause 0 Accident 0 Homicide El Suicide ri❑Undetermined ❑Pending Circumstances Investigation Medical Certifier Name Title Thomas Kandora MD Address 319 Broadway,Fort Edward Town,New York 12828 14 M Death Certificate Filed District Number Register Number v City, Town or Village Fort Edward 5755 57 El Burial Date Cemetery or Crematory i 10/23/2018 Pine View Crematory ❑Entombment Address ®Cremation 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 s " Date Cemetery Address Disinterment 1,Q Reinterment Date Cemetery Address Permit Issued to Registration Number AA A 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 10/23/2018 Registrar of Vital Statistics Aimee Mahoney(Etectronica Signed) (signature) DistrictPlace Number 5755 Fort Edward, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition 1D 115 11 i Place of Disposition 'F^ti— ��,i--- (address) (section) (lot number 31400° (grave number) Name of Sexton or Person in Charge of Pr mises L/��``" (please print) Signature Title frIP A9 (over) DOH-1555 (02/2004)