Shipley Jr, Henry NEW YORK STATE DEPARTMENT OF HEALTH # 523
Vital Records Section i i Burial - Transit Permit
Name First Middle Last Sex
Mi Henry J. Shipley QL Male.
Date of Death Age If Veteran of U.S. Armed Forces,
El 08/10/2014 68 yrs. War or Dates ' 66— ' 68
Place of Death Hospital, Institution or
City, Town or Village Town of Ft. Ann Street Address 5620 Pavilion Way
Manner of Death Natural Cause 0 Accident 0 Homicide 0 Suicide Undetermined ❑Pending
Circumstances Investigation
La
Medical Certifier Name Title
a Max Crossman MD.
'` Address
'<3 Poultney St. , Whitehall, NY.
Deat . icate Filed District Number Register Number
i Ci , Tow or Village Fort Ann 5754
Date Cemetery, or Crematory .
❑Burial 08/12/2014 PineView Crematorium
Address
❑x Cremation Queensbury, NY. 12804
gDate Place Removed
1� �Removal and/or Held
. and/or Address
iHold
Date Point of
g Q Transportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
ini Permit Issued to Registration Number
M Name of Funeral Home Mason Funeral Home 01117
iiig Address
18 George St. , Fort Ann, NY. 12827
<' > Name of Funeral Firm Making Disposition or to Whom
simsi Remains are Shipped, If Other than Above
Address
W
Permission is hereby granted to dispose of the human rem ins described above in ' ated.
!iiiiq Date Issued 0 8/1 2/1 4 Registrar of Vital Statistics i,.., e y,Z.
(sign re)
iN District Number.5754 Place / g 2-7
I certify that the remains of the decedent identified above were dispose of in accordance with this permit on:
f- �
WDate of Disposition g/13D4 Place of Disposition "C attar Cn,rct i'i"
X (address)
(1.1
N
cc (section) 4lot number) C (grave number)
GName of Sexton or Person in Charge of Premises nrt ,- Jeardif
g (please print)
W Signature 41 �� Title C MtU1C.
(over)
DOH-1555 (9/98)