Shaw, Carol f `1
4 bsq
NEW YORK STATE DEPARTMENT OF HEALTH .
Vital Records SectionBurial - Transit Permit
Name First Middle Last Sex
P. Carol R.Shaw Female
Date of Death Age If Veteran of U.S_Armed Forces,
08/27/2017 74 Years War or Dates
Place of Death Hospital, Institution or
s;.
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death j Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
41 Circumstances Investigation
Medical Certifier Name Title
Stephen Perazzelli MD
-63 Address
100 Park St,Glens Falls,New York 12801
-541
Death Certificate Filed District Number Register Number
At S
10 City, Town or Village Glens Falls 5601 459
¢-❑Burial Date Cemetery or Crematory
08/30/2017 Pine View Crematory
. 0 Entombment-� Address
®Cremation Queensbury Town, New York
Date Place Removed
.,.E.;❑Removal and/or Held
and/or Address
i Hold
Date Point of
❑Transportation Shipment
y by Common Destination
Carrier
6.
❑Disinterment Date Cemetery Address
'Y°'" Date Cemetery Address
❑Reinterment
it Permit Issued to Registration Number
ill Name of Funeral Home Alexander Baker Funeral Home 00037
Address
3809 Main St,Warrensburg,New York 12885
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
t Address
P• ermission is hereby granted to dispose of the human remains described above as indicated.
, - D• ate Issued 08/30/2017 Registrar of Vital Statistics &benACurtis ECectronicallySigned
(signature)
,._
District Number 5601 Place
t ` Glens Falls, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition tj31In Place of Disposition '661,tL cw-9tOf.....
(address)
(section) 4(lot number) (grave number)
t- N• ame of Sexton or Person in Charge of P emises I 11c t `L 3N►t+
"- (ple se print)
Signature 41 Title CR EMIR MIL
(over)
DOH-1555 (02/2004)