Shaw, Judith NEW YORK STATE DEPARTMENT OF HEALTH 95'1
Vital Records Section Burial - Transit Permit
T Name First Middle ' ."1 Last Sex
Judith Ann Shaw Female
Date of Death Age If Veteran of U.S. Armed Forces,
August 18, 2012 59 War or Dates
ZPlace of Death Hospital, Institution or
W City, Town or Village Glens Falls Street Address Glens Falls Hospital
W Manner of Death J Natural Cause El Accident Homicide Suicide Undetermined El Pending
Circumstances Investigation
W Medical Certifier Name Title
0 Gary Scidmore,
Address
1340 State Route 9 Lake George, NY 12845
Death Certificate Filed District Number Registe,X fiber
City, Town or Village 56e f , �
❑Burial Date Cemetery or Crematory
August 22, 2012 Pine View Crematorium
❑Entombment Address
Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
and/or Address
h Hold
Date Point of
aTransportation Shipment
(t) by Common Destination
0 Carrier
Disinterment Date Cemetery Address
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
I— Remains are Shipped, If Other than Above
2 Address
i�
W
a' Permission is hereby granted to dispose of the human remains described '
above as ndi e .
Date Issued Q�� �cv2_- Registrar of Vital Statistics sa;ee/
(signature)
District Number ��O/ Place 6/10'.2s F�l'!4, /j/ce /9k)/
I certify that the remains of the decedent identified above were disposed of in accordance� with this permit on:
w Date of Disposition B-2y-it_ Place of Disposition �Vtuo t s+Co—
W (address)
ce (section) (iqt number) (� (grave number)
O Name of Sexton or Person in Charge o remises �hr, -��►+�
^� (plea a print)
W Signature Title 0145
Lr..
(over)
DOH-1555 (02/2004)