Parker, Shirley NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section I- . _ , Burial - Transit Permit
Name First Middle Last Sex
Shirley Ann Parker Female
Date of Death Age If Veteran of U.S. Armed Forces,
February 6, 2016 82 War or Dates
I Place of Death Hospital, Institution or
W City, Town or Village Granville Street Address 94 County Rte 27
Manner of Death Natural Cause ❑ Accident In Homicide ❑ Suicide ❑ Undetermined ❑ Pending
W Circumstances Investigation
W Medical Certifier Name Title
L'1` Philip J Gara Jr. MD,
Address
327 Broadway Fort Edward, NY 12828
Death ificate Filed District Number Register Number
City, ow or Village G RAN 6-7 SG 5
❑Burial Date Cemetery or Crematory
February 9, 2016 Pine View Crematorium
❑Entombment Address
IE Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
and/or Address
N Hold
7) Date Point of
eL ❑Transportation Shipment
(I) by Common Destination
CI Carrier
❑ 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
2 Address
W
W'i'i'
a" Permission is hereby granted to dispose of the human remains described abov as indicated.
Date Issued oa Jn�lao« Registrar of Vital Statistics ),--11 -3/14-eg,-,4., a. 6
(signature)
District Number s7 s--10Place -TOWN 0 F G i1-A-N tLuc
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I-
W Date of Disposition 02/09/2016 Place of Disposition Quaker Road Queensbury,NY 12804 pi`,y-,e,v Gre."cd,r y
2 (address)
W
CO
(section) (lot number) (grave number)
0 Name of Sexton or Person in Charge of Premises o e,roityy u.,,';iQ,S
Z I (please print)
W Signature 4, -e .> Title CrG rN4c'r
(over)
DOH-1555 (02/2004)