Shaw, Scott NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Scott Bidwell Shaw Male
Date of Death Age If Veteran of U.S. Armed Forces,
September 13, 2015 71 War or Dates
I' Place of Death Hospital, Institution or
w City, Town or Village Hudson Falls Street Address 56 Main Street
ej Manner of Death 0 Natural Cause El Accident Homicide 0 Suicide Undetermined ri Pending
Circumstances Investigation
W Medical Certifier Name Title
Max Crossman MD,
Address
Whitehall Family Health Whitehall, NY
Death Certificate Filed District Number Register Number
City, Town or Village .5" 7 G- /d2.
❑Burial Date Cemetery or Cre 'tory
September 15, 2015 Pine Vie, rematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z Removal and/or Held
O and/or Address
F Hold
Date Point of
p, n Transportation Shipment
(I by Common Destination
t] Carrier
Disinterment Date Cemetery Address
ElReinterment 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
• Address
W
a" Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued �T-/(./-do/5-Registrar of Vital Statistics O ,,,� _ c c� �
0 (signature)
District Number 5- -7,1 6 Place V i tl la? 6.-1' a, c ah /r G l/S
▪ I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 09/15/2015 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
W
(section) jot number) (grave number)
pName of Sexton or Person in Charge of Premises ^"`f{
z Ar (pl se print)
UJJ Signature Title riviMoit
(over)
DOH-1555 (02/2004)