Shaw, Eleanor NEW YORK STATE DEPARTMENT OF HE
Vital Records Section c - .�
Burial - Transit Permit
n Name First Middle Last Sex
ki Eleanor H. Shaw Female
fry ;f
D• ate of Death Age If Veteran of U.S. Armed Forces,
;; J• uly 13,2013 78 War or Dates
'''g Place of Death Hospital, Institution or
City, Town or Village Queensbury Street Address 4 Lynnfield Drive
' Manner of Death x Natural Cause Accident C Homicide E Suicide n Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Susan Weaver,MD
Address
W Albany,NY
f0.fy' Death Certificate Filed District Number Regis r Number
vg, City, Town or Village Queensbury,NY 5657
❑Burial Date Cemetery or Crematory
July 16, 2013 Pine View Crematory
❑Entombment Address
I:Cremation Quaker Road, Queeensbury, NY 12804
Date Place Removed
z C Removal and/or Held
and/or Address
E Hold
V) _
0 Date Point of
N C Transportation Shipment
p by Common Destination
Carrier _
Date Cemetery Address
E Disinterment
Reinterment Date Cemetery Address
<t' Permit Issued to Registration Number
RA Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
f' Address
407 Bay Road, Queensbury, NY 12804
�r� Name of Funeral Firm Making Disposition or to Whom
'''' Remains are Shipped, If Other than Above
Address
-;.:',A Permission is hereby granted to dispose of the human r m ins described ove as indicated.
} Date Issued (� + l Registrar of Vital Statistics � C�_�( , 9 �f1,��
:,.
g': (signature)
gm District Number Place
5657 Queensbury,NY
£f
F- I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
�Z Disposition1116j13 DispositionU
Date of Place of ,�, �w,1 rtr►tfGri,.-
W (address)
U)
re (section) (lot number) (grave number)
pName of Sexton or Person 'n Charge of Pr ises t '{ r- 30wit
Z Cplease print)
W Signature 1— Title Ct i0114.
(over)
DOH-1555(02/2004)