Shook, Elsie NEW YORK STATE DEPARTMENT OFrriEALT'H ( �
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Elsie Marie Shook Female
Date of Death Age If Veteran of U.S. Armed Forces,
October 11,2017 88 War or Dates
▪ Place of Death Hospital, Institution or
Z City, Town or Village Bolton Street Address 27 Stewart Avenue
pManner of Death x Natural Cause Accident I I Homicide Suicide Undetermined 1 Pending
Circumstances Investigation
to Medical Certifier Name Title
a Bryan Smead MD
Address
Bolton Health Center,Bolton Landing,NY 12814
Death Certificate Filed District Number Register Number
City, Town or Village T/O Bolton 5650 u
❑Burial Date Cemetery or Crematory
October 12,2017 Pine View Crematory
Entombment Address
®Cremation 21 Quaker Rd., Queensbury, NY 12804
Date Place Removed
Z I I Removal and/or Held
52 and/or Address
H Hold
Cl)
O Date Point of
N Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Alexander-Baker Funeral Home 00037
Address
3809 Main Street,Warrensburg,NY 12885
Name of Funeral Firm Making Disposition or to Whom
N Remains are Shipped, If Other than Above
Address
QC.
tW;
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 10\13\a(-),j Registrar of Vital Statistics i L
(signature)
District Number 5650 Place T/O Bolton
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
/6
W Date of Disposition A J!I O Place of Disposition -Pni (2 a ta✓
W (address)
N
(section) (lo(number) (grave number)
pName of Sexton or Person in Charge of Premiss t^a Li v
�Z (ple#se print)
Signature Title erfahorc
(over)
DOH-1555 (02/2004)