Farmer, Shawn 4 °5-
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last 1 Sex
Shawn Peter Farmer I Male
Date of Death Age l If Veteran of U.S.Armed Forces,
September 25,2012 51 War or Dates
i_ Place of Death Hospital, Institution or
Z City, Town or Village Jay , Street Address 25 Covered Bridge Lane
p Manner of Death Ant Natural Cause f]Accident (— Homicide n Suicide Undetermined Pending
VCircumstances Investigation
w Medical Certifier Name Title
Steven Emmons M.D.
Address
2233 State Rt.86,Saranac Lake,NY 12983
Death Certificate Filed District Number i Register Number ..
City, Town or Village Jay ) 5'1
❑Burial Date 1 Cemetery or Crematory
❑Entombment September 27,2012 j Pine View Crematory
Address
®Cremation 21 Quakeii•Rd.,Queensbury,NY 12804
Date Place Removed
Z �Removal and/or Held
O and/or Address
N Hold
N
0 Date I Point of
N n Transportation i Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment
I Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home M.B.Clark,Inc. 01075
Address
2310 Saranac Ave.,Lake Placid,NY 12946
Name of Funeral Firm Making Disposition or to Whom
i- Remains are Shipped, If Other than Above
2 Address
mu
a
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 09-27-2012 Registrar of Vital Statistics C /1I-Q,jaCk-a. -I i t.
(signature) I J
District Number 1554 Place 70 uir op tjQ(.)
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition r1lig1I L Place of Disposition Qa0tu, Cf )v&-:
W (address)
U)
E
(section) // --(lot number) (grave number)
p Name of Sexton or Person in Charge f Premises hi 9 �5• ,'�.
Z 1�(please print)
w
Signature 4Title atii Mrtrait
(over)
DOH-1555 (02/2004)