Shepard, Nancy NEW YORK STATE DEPARTMENT OF HEALTH i 5-6 5
Vital Records Section Burial - Transit Permit
. Name First Middle Last Sex
Nancy Claudette Shepard Female
Date of Death Age If Veteran of U.S. Armed Forces,
06/26/2017 82 Years War or Dates
• Place of Death Hospital, Institution or
iti City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death,Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
lAi Medical Certifier Name Title
9 Julian Marynczak PA
Address
100 Park St,Glens Falls,New York 12801
y` Death Certificate Filed District Number Register Number
k City, Town or Village Glens Falls 5601 355
❑Burial
Date Cemetery or Crematory
07/03/2017 Pine View Crematorium
❑Entombment Address
®Cremation Queensbury Town, New York
Date Place Removed
❑Removal and/or Held
and/or Address
Hold
Date Point of
µ°' ❑Transportation Shipment
by Common Destination
Carrier
❑Disinterment Date Cemetery Address
Date Cemetery Address
❑Reinterment
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
4'
W.
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 06/28/2017 Registrar of Vital Statistics 4jpbertA-Curtis E(ectmt:icaffySigned
(signature)
District Number 5601 Place Glens Falls, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W. Date of Disposition )/S In Place of Disposition 'f,k�»tu,✓ t en--.-
(address)
41
CO
(section) of number) (grave number)
0
Name of Sexton or Person in Charg of Premises lAfts StM4tb/
zr (pleas print)
Signature 6 Title MCA
(over)
DOH-1555 (02/2004)