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Sherman, Shirley NEW YORK STATE DEPARTMENT OF HEALTH '3`I tra_ Vital Records Section Burial - Transit Permit Name First Middle Last Sex Shirley Jean Sherman Female Date of Death Age If Veteran of U.S. Armed Forces, June 15, 2016 85 War or Dates Z Place ath Hospital, Institution or W City ow or Village Queensbury Street Address The Stanton Nursing & Rehab. Center Manner of Death .i Natural Cause ❑ Accident ElHomicide I I Suicide ❑ Undetermined ❑ Pending W Circumstances Investigation U W Medical Certifier Name Title CI Kenneth France, Dr. Address 170 Warren Street Glens Falls, NY 12801 Deat ---'ficate File District Number Register Number City, ow. .r Village(1)U-e 2 f1 S b 1,_. ❑Burial Date Cemetery or Crematory June 17, 2016 Pine View Crematorium ❑Entombment Address ©Cremation Quaker Road Queensbury,NY 12804 Date Place Removed z El Removal and/or Held • and/or Address F- Hold Pine View Crematorium CO Date Point of 0. ❑Transportation Shipment Cl) by Common Destination p: Carrier Date Cemetery Address ❑ Disinterment ❑ 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 M Address , IX w a- Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued C+ j I 1 1 dal lP Registrar of Vital Statistics AQ\.Q k'Z)'`. (signature) District Number S U ( Place DV e�n by/` I certify that the remains of the decedent identified above were disp ed of in accordance with this permit on: W Date of Disposition 06/17/2016 Place of Disposition Quaker Road Queensbury,NY 12804 M (address) W (r) (section) liotnumber) (grave number) in Name of Sexton or Person in Charge of Premises ALI z4 (ple a print) W Signature / --- Title (Pt 1441-04. (over) DOH-1555 (02/2004)