Shewell, Madaline r . _ 1 'k 6
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
r Name First Middle Last Sex
'r% Madaline Dorothy Shewell Female
` Date of Death Age If Veteran of U.S. Armed Forces,
September 15,2016 92 War or Dates
! Place of Death Hospital, Institution or
City, Town or Village ranville Street Address The Orchard Nursing Centre,Inc.
Manner of Death Natural Cause ❑Accident ❑Homicide n Suicide n Undetermined I I Pending
Circumstances Investigation
Medical Certifier Name ,•\ Title
0. Address '
' Death -rtificate Filed District Number Register Number
;, City ow� or Village eranV�(I�-� 3r1 0 sv
❑Bu . Date Cemetery or Crematory
September 16, 2016 Pine View Crematorium
❑Entombment Address
❑x Cremation 51 Quaker Road, Queensbury,NY 12804
Date Place Removed
Z
Removal and/or Held
and/or Address
Hold
N
0 Date Point of
N ❑Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
C Reinterment Date Cemetery Address
%r Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
r
w ; Address
=1 407 Bay Road,Queensbury, NY 12804
1 Name of Funeral Firm Making Disposition or to Whom
iRemains are Shipped, If Other than Above
` ' Address
Permission is hereby granted to dispose of the human remains described above as indicated.
{ Date Issued t l i5/c biLp Registrar of Vital Statistics Q
.' Clf- ` (signature)
District Number 51 ap Place Owi-\ 6 ,-\S,tk.e
t,f:
F I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition I ill j16 Place of Disposition .�Crni.Ucr✓ �cvytt r!uN
W (address)
Ce (section) (lot number) (grave number)
QName of Sexton or Person in Charge of Pre ises r 4,- .�ih1Ll1
Z (pease print) /
W 006 Signature Title 1
(over)
DOH-1555(02/2004)