Shannon, James t _ , 4 4t9
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
James Bolger Shannon Male
Date of Death Age If Veteran of U.S. Armed Forces,
March 16, 2017 66 War or Dates Vietnam
Place of Death Hospital, Institution or
w City, Town or Village Glens Falls Street Address Glens Falls Hospital
Ouj Manner of Death/Natural Cause 0 Accident El Homicide El Suicide El
Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
Aqeel A. Gillani, M.D.',
Address
102 Park Street, Glens Falls, New York 12801
Death Certificate Filed District Number Register i•. -r
City, Town or Village 5601 e a'
El Burial Date Cemetery or Crematory
r r: March 21, 2017 Pine View Crematorium
❑Entombment Address
- ®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
7 El Removal and/or Held and/or _Address
H Hold
t/ Date Point of
0 Transportation , Shipment
Cl) by Common Destination
#, Carrier
r Disinterment Date Cemetery Address
'' Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
I--- Remains are Shipped,If Other than Above
f Address
tt*` Permission is hereby ranted to dispose of the human remains des i, • :j e n c ted.
Date Issued 051,0 20/2 Registrar of Vital Statistics ,�% "
/� ��^^ // (signature)
District Number 5601 Place Ilex. A-X , /(3Y4
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
2Z
11! Date of Disposition 0344/2017 Place of Disposition Quaker Road Queensbury,NY 12804 POje/,. 1-f&logy,
2 (address)
CrX
W (section) (lot tuber) (grave number)
d �/ C✓ A j
rl Name of Sexton r Pe on in Charge of Premises 1/-"l , (7c 444 a_(. t 6
z (please pfint)
Signature Title Lreri'JGol
(over)
DOH-1555 (02/2004)