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Shaw, Frank -4I)9 NEW YORK STATE DEPARTMENT OF HEALTH A Vital Records Section Burial - Transit Permit Flt Name Firstlel Middle Last Sex Frank Windsor Shaw Female ill Date of Death Age If Veteran of U.S. Armed Forces, February 5, 2016 56 War or Dates Place of Death Hospital, Institution or City, Town or Village Glens Falls Street Address 70 South Street Ri Manner of Death J Natural Cause El Accident 0 Homicide ElSuicide 0Undetermined � Pending Circumstances Investigation fill Medical Certifier Name Title Paul Bachman, M.D. Address 3767 Main Street Warrensburg, NY 12885 Death Certificate Filed District Number Register N mber City, Town or Village J t C) / 6 Date Cemetery or Crematory ❑Burial February 10, 2016 Pine View Crematorium 1: ;❑Entombment Address ®Cremation Quaker Road Queensbury,NY 12804 4 E. Date Place Removed Removal and/or Held and/or Address Hold Date Point of ❑Transportation Shipment by Common Destination ' Carrier Disinterment Date Cemetery Address Date Cemetery Address Reinterment 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 Remains are Shipped, If Other than Above Address€. s tom, Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 2/9 f 1 6 Registrar of Vital Statistics CkAJ-y\-e (signature) ` 6C�S ct IIS, N District Number ��©1 Place 'e I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: til Date of Disposition 02/10/2016 Place of Disposition Quaker Road Queensbury,NY 12804 bile,vr,y' (Je cdory (address) LE-. (section) (lot number) (grave number) Name of Sexton or Person in Charge of Premises �P� ��' (please print) Signature A4 Title C.)1e>>719 -)C (over) DOH-1555(02/2004)