Labshere, Shelly itCO
NEW YORK STATE DEPARTMENT OF HEALTH ` * 4 p B �
Vital Records Section urial - Transit Permit
,
` s Name First Middle Last Sex
Shelly Lee Labshere Female
DDate of Death Age If Veteran of U.S. Armed Forces,
August 21, 2013 46 War or Dates
,> Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
:` Manner of Death El Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
Medical Certifier Name Title
Agee!A. Gillani, M.D. Dr.
! - Address
�-, 102 Park Street Glens Falls, NY 12801
Death Certificate Filed District Number 6a( Register NummJbe „7
City, Town or Village Glens Falls
reg❑Burial Date Cemetery or Crematory
—Address
23, 2013 Pine View Crematory
, ❑Entombment Address
;z ®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
and/or Address
Hold
Date Point of
❑Transportation Shipment
by Common Destination
Carrier
;; Date Cemetery Address
❑ Disinterment
14
❑ Reinterment Date Cemetery Address
4r Permit Issued to Registration Number
ll Name of Funeral Home M. B. Kilmer Funeral Home 01079
!, Address
82 Broadway, Fort Edward NY 12828
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
'g Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued g/2 3 //3 Registrar of Vital Statistics w `N
// (signature)
b
District Number 560 ) Place S PG, 1 1 sa IV
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
r Date of Disposition 08/23/2013 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
(section) (lot number) (grave number)
Name of Sexton/ erso r of Premises 5 i 4 kJ J,
Signature ? Title
C-pleat)
4 I
(over)
DOH-1555 (02/2004)