Heath, Sharyn NEW YORK STATE DEPARTMENT OF HEALTH e 'r 13
Vital Records Section Burial - Transit ta ermit
Name First Middle Last Sex
Sharyn L. Heath Female
Date of Death Age If Veteran of U.S. Armed Forces,
Feb. 26, 2014 68 yrs. War or Dates no
10,!, Place of Death Hospital, Institution or
wCity, Town or Village Fort Ann Street Address 31 Thomas Rd.
W Manner of Death w Natural Cause ❑Accident ❑Homicide ❑Suicide El Undetermined ri❑Pending
Circumstances Investigation
tu Medical Certifier Name Title
t Gordon Thomas 0.O.
Address
79 North St. , Granville, NY. 12832
Death Certificate Filed District Number Register Number
City, Town or Village Fort Ann 5754
i El Burial Date Cemetery or Crematory
Feb. 28, 2014 PineView Crematorium
['Entombment Address
13Kremation Queensbury, NY.
Date Place Removed
Removal and/or Held
.. and/or Address
N Hold
{
0 Date Point of
bli ❑Transportation Shipment
a by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Ei! Permit Issued to Re istration Number
Name of Funeral Home Mason Funeral Home 1D 1 1 17
Mi Address
18 George St. , PO. Box 277, Ft. Ann, NY. 12827
Name of Funeral Firm Making Disposition or to Whom
• Remains are Shipped, If Other than Above
• Address
It
,' Permission is hereby granted to dispose of the human re sins described ab, e as i .icated..y----
Date Issued Feb. 27, 2( gistrar of Vital Statistics zA__ vf � �,9! z :
(signature)
District Number 5754 Place Town of Fort A , NY.
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
i .
ta Date of Disposition /14I)9 Place of Disposition ',imika tler:+..—
(address)
tti
Cr (section) (lot number) r. (grave number)
• Name of Sexton or Person in Charge Premises io itt, --Vim it
* ► (please print)
44 Signature Title CIZ.071476e,
(over)
DOH-1555 (02/2004)