Shannon, Karen NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
�" Name First Middle Last I Sex
Female
r , Karen E.Shannon _
Date of Death Age If Veteran of U.S. Armed Forces,
kirA 44
09/21/2017 163 Years War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
iWI Manner of Death Cx Natural Cause 1 Accident lu Homicide Suicide I i Undetermined 1 1 Pending
Circumstances Investigation
1170,
pm Medical Certifier Name Title
f Michael Miles MD
Address
, 100 Park St,Glens Falls,New York 12801 _
--' Death Certificate Filed J District Number Register Number
City, Town or Village Glens Falls + 5601 500
Burial Date Cemetery or Crematory
09/22/2017 PineView Crematorium
_.]Entombment
e Address
• Date - f
Cremation Queensbury Town, New York Place Removed
n I Removal and/or Held
and/or Address
Hold
�
�� Date T Point of
`rri` 'I Transportation Shipment
$-„, by Common Destination
k Carrier
L Disinterment
Date T Cemetery Address
ti
4 j Reinterment Date Cemetery Address
liejl
Permit Issued to Registration Number
Name of Funeral Home Mason Funeral Home j 01117
34
Address
-' 18 George St Po Box 277,Fort Ann,New York 12827-0277
ems,`= Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
,. : Address
g
' �. Permission is hereby granted to dispose of the human remains described above as indicated.
'a Date Date Issued 09/22/2017 Registrar of Vital Statistics R9 ben ACurtis cECectronicaltySigned
(signature)
o
•
g 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:
t Date of Disposition 91Zisi f Place of Disposition .ii'&i4 t a}esi,,•..
-. (address)
p (section) flotn umber) St_ (grave number)
IV 4
" Name of Sexton or Person inCharge of Pre ses
// (p1e a print)
rrr
op Signature — _ 4( Title ___ ! ►A10+�
(over)
DOH-1555 (02/2004)