Shepard, Ronald NEW YORK STATE DEPARTMENT OF HEALThf ' 114
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Ronald P. Shepard Male
Date of Death Age If Veteran of U.S. Armed Forces,
Jan. 29, 2014 83 Yrs. War or Dates 1 948-1 952
Place of Death Hospital, Institution or
W City, Town or Village Glens Falls Street Address Glens Fals Hospital
Manner of Death❑Natural Cause ❑Accident ❑Homicide ElSuicide ❑Undetermined ❑Pending
Circumstances Investigation
W Medical Certifier Name Title
D Shahid Ahmed MD.
Address
100 Park St. , Glens Falls, NY. 12801
Death Certificate Filed District Number Register Number
City, Town or Village Glens Falls 5601 5 2
❑Burial Date Cemetery or Crematory
Jan. 30, 2014 PineView Crematorium
El Entombment Address
;< �c]Cremation Oueensbury, NY. 12804
Date Place Removed
Z El❑Removal and/or Held
la and/or Address
t.7117. Hold
0 Date Point of
co Transportation Shipment
0 by Common Destination
Carrier
❑Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Mason Funeral HomeRegistration Number
7
Name of Funeral Home00
Address
P.O. Box 277, Fort Ann, NY. 12827
Name of Funeral Firm Making Disposition or to Whom
1-4 Remains are Shipped, If Other than Above
2 Address
CC
fJ
fl' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued Jan. 30, 2 Registrar of Vital Statistics I C A A )yN.g W
(signatur )
District Number 5601 Place City of Glens Falls, NY.
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
LEI Date of Disposition (/3)/tj Place of Disposition -Ufa u k,.,,
(address)
Ili
U)
CC (section) i (lot number) (grave number)
QName of Sexton or Person in Charge o Premises , f :Stn�elt
(p ase print)
Signature `► Title lIN
(over)
DOH-1555 (02/2004)