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Simione, Shelley 175 NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex Shelley Irene Simione Female Date of Death Age If Veteran of U.S. Armed Forces, March 3, 2016 61 War or Dates I- Place of Death Hospital, Institution or City, Town or Village Glens Falls Street Address Glens Falls Hospital CI Manner of Death 'Natural Cause Accident Homicide Suicide � Undetermined Pending Circumstances Investigation W Medical Certifier Name Title Frances Bollinger MD, Address 161 Carey Rd Queensbury, NY 12804 Death Certificate Filed District Number Register Number City, Town or Village 5601 J ( ❑Burial Date Cemetery or Crematory March 7, 2016 Pine View Crematorium ❑Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed z El Removal and/or Held 0- and/or Address F.: Hold Date Point of a: Transportation Shipment co by Common Destination C) Carrier 11 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 It— Remains are Shipped, If Other than Above Address CL W Permission is hereby granted to dispose of the human remains described above as indicated. ; Date Issued 31? 11 6 Registrar of Vital Statistics We ,.t .A./.14.1 (signature) District Number 5601 Place G BAN"-s FG 1\s, p-) y I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition 03/07/2016 Place of Disposition Quaker Road Queensbury,NY 12804 (address) W< (section) dot number) (grave number) Name of Sexton or Person in Char a of Premises NA IrV Star t (plebse print) U Signature Zt —; f Title ll "+til� (over) DOH-1555 (02/2004)