Armstrong, Shirley # 14 # 6 cci
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
1111 Name First Shirley Middle T. Last SexSex F
Date of Death 1 1 /3/2 01 3 Age 91 If Veteran of U.S. Armed Forces,
War or Dates No
Place of eath Hospital, Institution or
CityIII ,Town r Village Fort Edward Street Address Fort Hudson Nursling Center
ci Manner of- eath Natural Cause El Accident 0 Homicide El Suicide riUndetermined �Pending
Uri 'I Circumstances Investigation
at Medical Certifier Name Title
Charlene B. Harrington PA
Address 327 Broadway Fort Edward NY 12828
Death.„Qeficate Filed District Number Register Number
>"> City own r Village re iq 7-EDtd,M/e D .5l?, 5' 6 n
❑Burial Date 1 1 /4/201 3 Cemetery or Crematory Pine View Crematorium
❑Entombment Address
[ Cremation Queensbury, NY 12804
Date Place Removed
#❑Removal and/or Held
and/or Address
C: Hold
C
0
Date Point of
ti u Transportation Shipment
L by Common Destination
Carrier
iiiiiiiiEl Disinterment Date Cemetery Address
Q Reinterment Date Cemetery Address
IN Permit Issued to Renistration Number
Name of Funeral Home Mason Funeral Home 0 II I) 7
Address
18 George Street Fort Ann, NY 12827
Name of Funeral Firm Making Disposition or to Whom
14 Remains are Shipped, If Other than Above
Address
2
ILI
` Permission is he eb granted to dispose of the human r ins described a ve a ndicated.
iiiii Date Issued I� /3 Registrar of Vital Statistic
------- (signatur) ,
iai District Number7S" Place
I certify that the remains of the decedent identified a ve were disposed of in accordance with this permit on:
I Date of Disposition 6103 Place of Disposition f nbU+Ic.B Gt1
,,.44-
(address)
tii
to
cC (section) (lot number (grave number)
Name of Sexton or Person in Charge of remises (lot
'., please print)
iii
Aiiii Signature At,. Title j' er)ttii3rt
(over)
DOH-1555 (02/2004)