Shevlin, Patricia .f, . ..„ t 7
NEW YORK STATE DEPARTMENT OF HEALTH 6S—
Vital Records Section Burial - Transit Permit
gi Name First Middle Last Sex
Patricia Ann Shevlin Female
Date of Death Age If Veteran of U.S. Armed Forces,
05/06/2013 74 years War or Dates
a of Death Hospital, Institution or
-'a City, ovjJ/ X Glens Falls Street Address
Imo= ...c park st glen falls, n y 12801
ci anner of Death ice'„Natural Cause ❑Accident El Homicide ❑Suicide 0 Undetermined Pending
W Circumstances Investigation
0.
to Medical Certifier Name Title
41 .Insaph C Mihinda M D
Address
20 Murray Street Glens Falls, N Y 12801
Wi Death Certificate Filed District Number Register Number
City, Tovo�j iR X Glens Falls 5601 200
IE❑Burial Date Cemetery or Crematory
❑Entombment 05/08/2013 Pine View Crematory
Address
atiremation Queensbury, NY .
Date . Place Removed
P❑Removal and/or Held
and/or
r Address
f
Hold
0 Date Point of
Eli Trans ortation
❑ p Shipment
f by Common Destination
igi Carrier
NiiDisinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Mii Name of Funeral Home Maynard D. Baker Funeral Home 01130
Address
11 Lafayette Street Queensbury, N Y 12804
:lii Name of Funeral Firm Making Disposition or to Whom
-; Remains are Shipped, If Other than Above
Address
tr
E
CL
` Permission is hereby granted to dispose of the human remains described abov as i c ted.
Date Issued 05/08/2013 Registrar of Vital Statistics
(sig.tature)
District Number 5601 Place Glens Falls/zoK /02 /
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
(� p�fI
t Date of Disposition Jam- /0-l' Place of Disposition �i��.i A4-1 C' .1-06( 4,
i (address)
ta
III (section) d (lot number (grave number)
: Name of Sexton or Perso in Charge of remises ,.r Jot. L4-
yZ (please print)
Signature Title Cftt-
(over)
DOH-1555 (02/2004)