Shaughnessy, Gloria -44 1
NEW YORK STATE DEPARTMENT OF HEALTH -71,(
Vital Records Section ^ . N Burial - Transit Permit
Name First Middle Last Sex
Gloria Shaughnessy Female
Date of Death Age If Veteran of U.S. Armed Forces,
12/06/2013 66 years War or Dates
fir%: P. of Death Hospital, Institution or
ity, owj(iIXXX Glens Falls Street Address park st glens falls. n y
a ner of DeathrWtural Cause El Accident Ei Homicide 0 Suicide 0Undetermined 0 Pending
iii Circumstances Investigation
W Medical Certifier Name Title
Q Joseph C' Mihinria M D
Address
20 Murray Street Glens Falls, N Y 12801
-.th Certificate Filed District Number Register Number
MP owX)()(il XXX Glens Falls 5601 516
■Burial Date Cemetery or Crematory
Entombment 12/09/2013 Pineview Crematory
Address
iC4yemation Queensbury, N Y 12804
Date Place Removed
2 ❑Removal and/or Held
and/or Address
Hold
0 Date Point of
03 ❑Transportation Shipment
0 by Common Destination
Carrier
Q Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Edward L. Kelly Funeral Home 00519
Address
Schroon Lake, N Y 12870
Name of Funeral Firm Making Disposition or to Whom
1 Remains are Shipped, If Other than Above
2 Address
Ui
'''` Permission is hereby granted to dispose of the human re - ins de ribed ab ve as indicat
Date Issued 12/09/2013 9 '7
Registrar of Vital Statistics
(signature)
District Number 5601 Place Glens Falls /UV /2 K1
certify that the remains of the decedent identified above were d. posed of in accordance with this permit on:
lLI Date of Disposition IA-(U 13 Place of Disposition gl.Vt+43to f
2 (address)
W
CC (section) (1 t number) (grave number)
CI Name of Sexton or Perso in Charge f Premises r aW"!
ig-
(pleas'W print)
ILI
Signature Title Mei,XcUr_
(over)
DOH-1555 (02/2004)