McLaughlin, Shirley NEW YORK STATE DEPARTMENT OF HEALTH # 6-00
Vital Records Section * - - Burial - Transit Permit
Name First Middle Last Sex
Shirley Ann McLaughlin Female
Date of Death Age If Veteran of U.S. Armed Forces,
October 28, 2013 77 War or Dates
Place of Death Hospital, Institution or
W City, Town or Village Hudson Falls Street Address 18 East LaClaire Street
WW Manner of Death Natural Cause IIIAccident ElHomicide ElSuicide ❑ Undetermined ri❑ Pending
Circumstances Investigation
W Medical Certifier Name Title
CI Mark Hoffman MD,
Address
420 Glen St. Glens Falls, NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village /1-1A.456 N Fa-Ifs 5'7 a 6, /60
❑Burial Date Cemetery or Crematory
November 4, 2013 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
• and/or Address
I Hold SARATOGA NATIONAL
CO Date Point of CEMETEKY
rL• ❑Transportation Shipment
CO by Common Destination
CI Carrier
Date Cemetery Address
❑ Disinterment
Reinterment
❑ Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
t Remains are Shipped, If Other than Above
2 Address
W
ICL Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 91)-A 9-AO/3 Registrar of Vital Statistics `J � . /7) (-
(signature)
District Number 721,, Place I fi ,,_ t y � � V41-6$, n54
II—' I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w „�.V Date of Disposition ii JSii Place of Disposition 14.w C/A ,‘._
(address)
W
CO
,j (section) (lot umber) (grave number)
tt
Name of Sexton or Person in Charge of P emises ill( .- 30"
z (please pint)
g
W Signature7 Title t!
(over)
DOH-1555 (02/2004)