Shaw, Donald 30
NEW YORK STATE DEPARTMENT OF HEALTH �
Burial - Transit Permit
Vital Records Section
Name First Middle Last Sex
Donald A. Shaw Male
Date of Death Age If Veteran of U.S. Armed Forces,
June 11, 2012 70 War or Dates
ZPlace of Death Hospital, Institution or
W]
City, Town or Village Lake George Street Address 1695 Bay Road
C Manner of Death j Natural Cause Accident Homicide Suicide Undetermined Pending
W Circumstances Investigation
0
WW Medical Certifier Name Title
CI Philip J Gara Jr. MD,
Address
_ 327 Broadway Fort Edward, NY 12828
Death Certificate Filed District Number Register Number
City, Town or Village iv 5 ) erb
❑Burial Date Cemetery or Crematory
June 13, 2012 Pine Vew Crematorium
❑Entombment Address
®Cremation Queensbury,NY 12804
Date Place Removed
ORemoval and/or Held
and/or Address
p Hold
5 Date Point of
a. Transportation Shipment
to by Common Destination
ID 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
F_- Remains are Shipped, If Other than Above
2 Address
W
8_ Permission is hereby granted to dispose of the human remain described above s 'ndicated.
Date Issued to_D. au/t Registrar of Vital Statistics A /,1.--
(signature)
District Number s.1 Place 64��.,,9 _
I certify that the remains of the decedent identified above were disposed� of in accordance with this permit on:
I—
W` Date of Disposition (4s4I1Z 1i Place of Disposition 'neVuJ (r�n.c,°rw--
2 (address)
W,
0)
fX (section) (lot number) (grave number)
a; Name of Sexton or Person in Charge of Premises �n°at .• Bier
z (please print)
W Signature (AL_ Title CutEi.QiA c UVt
(over)
DOH-1555 (02/2004)