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Shaw, Barbara NEW YORK STATE DEPARTMENT OF HEALTH t1 Z y Vital Records Section Burial - Transit Permit Name First Middle Last Sex Barbara Anne Shaw Female Date of Death Age If Veteran of U.S. Armed Forces, March 23, 2017 82 War or Dates Place of Death Hospital, Institution or 1 {:: City, Town or Village Moreau Street Address 26 Second Street LuO Manner of Death=Natural Cause El Accident ID Homicide Ej Suicide lip Undetermined ri Pending Circumstances Investigation W Medical Certifier Name Title Ca Glen Anderson, Address 1448 Route 9 South Glens Falls, NY 12803 Death Certificate Filed District N�.rth r_, Registepf)umber City, Town or Village Moreau `� J(� / d ❑Burial Date Cemetery or Crematory March 24, 2017 Pine View Crematory 0 Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed ZElRemoval and/or Held and/or Address Hold CO Date Point of 0 Transportation Shipment by Common Destination ileti Carrier Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home M. B. Kilmer Funeral Home- FE 01079 Address 82 Broadway, Fort Edward NY 12828 Name of Funeral Firm Making Disposition or to Whom e Remains are Shipped, If Other than Above Address 1 Permission is hereby granted to dispose of the human rem i escrib ab ve as indicated. Date Issued 51A 5) i-7 Registrar of Vital Statistics J ilak( g ture) p District Number (�� Place '3�1 gi.,eLivoid led /i z /c1a, I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: ut Date of Disposition 03/24/2017 Place of Disposition Quaker Road Queensbury,NY 12804 2 (address) CO IZ (section) �" (lot number) (grave number) Name of Sexton or Person in Charge o remises G �h� 'Gngl'f �; � (please print) Signature ////�� Title PI/VW (over) DOH-1555 (02/2004)