Shaw, Beatrice NEW YORK STATE DEPARTMENT OF HEALTH -1 - `r- I I I
Vital Records Section R \ Burial - Transit Permit
Name First Middle Last Sex
Beatrice Ann Shaw Female
Date of Death Age If Veteran of U.S.Armed Forces,
February 12, 2012 �� War or Dates
F- Place of Death Hospital, Institution or
in- City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death❑ Natural Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined El❑ Pending
Ili
Circumstances Investigation
U Medical Certifier Name Title
0 Marvin Davidowitz, M.D
Address
100 Park Street Glens Falls, NY 12801
Death Certificate Filed District Number Regitrumber
City, Town or Village 5601
❑Burial Date Cemetery or Crematory
February 23, 2012 Pine Vew Crematorium
❑Entombment Address
®Cremation Queensbury,NY 12804
Date Place Removed
7 ❑ Removal and/or Held
and/or Address
F. Hold
5-
0 Date Point of
EL ❑Transportation Shipment
CO= by Common Destination
15 Carrier
❑ Disinterment Date Cemetery Address
❑ Reinterment Date Cemetery Address
t.
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
H Remains are Shipped, If Other than Above
2 Address
IX
Ui
-; Permission is hereby granted to dispose of the human remains describ bove 'ndi
Date Issued 02 23/Zp/Z-Registrar of Vital Statistics ,7 `
/ _ (signature)
District Number 5601 Place 4 , /V
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
in Date of Disposition 5 Zh(1,p(•1,Place of Disposition Pr.c Vztw ��hA'rJ 'C`.�
X' (address)in re to
(section) (lot number) (grave number)
0 Name of Sexton or Person in Charge Premises Ri�.y ,-48 �ty�Il'
(please print)
Signature Title CV 41 --tlit,_
(over)
DOH-1555 (02/2004)