Shattuck, Elaine s NI
NEW YORK STATE DEPARTMENT OF HEALTH ' --
"3t1&
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Elaine C. Shattuck Female
Date of Death Age If Veteran of U.S. Armed Forces,
05/25/2014 60 years War or Dates
1 Place of Death Hospital, Institution or
utZ City, ToxxxxV
kitimx Saratoga S rings Street Address Sa ital
i Manner of Death❑fVatural Cause ❑p ratr)Accident ❑Homicide ❑Suicide determined ❑Pending
W Circumstances Investigation
ti Medical Certifier Name Title
Cl Rodney Ying MD
Address
59 Myrtle Street Saratoga Springs, Ny
Death Certificate Filed District Number Register Number
City, ToWXXIOtkRXX Saratoga Springs 4S01 246
<!>❑Burial Date Cemetery or Crematory
05/28/2014 Pinpview Cremates
❑Entombment Address ry
DI❑Cremation Queensbury, N Y
Date Place Removed
2 Removal and/or Held
0 ❑and/or
Address
Hold
O Date Point of
t1 Transportation Shipment
G! by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Densmore Funeral Home 00448
Address
7 Sherman Ave, Corinth, New York 12822
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
• Address
M.
Ili
`. Permission is hereby granted to dispose of the human remai?es ib abou ' dicated
Date Issued 05/27/2014 Registrar of Vital Statistics
(signature)
District Number 4501 Place Saratoga Springs
N
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
ILI Date of Disposition i"-Z%-iH Place of Disposition -ent.0i,.y C,.t w-c for,. ..
(address)
ill
at
IC (section) (lot number) ('_ (grave number)
0 Name of Sexton or Per n in Charge f Premises rt4rL J:4r4i
(p ase print)
• Signature (,, Title +ZEA
Wit
(over)
DOH-1555 (02/2004)