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Shaw, Alice NEW YORK STATE DEPARTMENT OF HEALTH 1 1 g Vital Records Section Burial - Transit Permit Name First Middle Last Sex Alice Shaw Female Date of Death Age If Veteran of U.S. Armed Forces, January 6, 2012 74 War or Dates Place of Death Hospital, Institution or W City, Town or Village Glens Falls Street Address Glens Falls Hospital Manner of Death Natural Cause ❑ Accident ❑Homicide ❑ Suicide ❑ Undetermined ❑ Pending Circumstances Investigation W Medical Certifier Name Title ©; Frances Bollinger MD, Address 1448 Route 9 South Glens Falls, NY 12803 Death Certificate Filed District Number 5 60 1 Register Number j 1 City, Town or Village 0 Burial Date Cemetery or Crematory January 9, 2012 Pine View Crematorium ❑Entombment Address ®Cremation Quaker Road Queensbury,NY 12804 Date Place Removed z ❑ Removal and/or Held • and/or Address p Hold _ CO Date Point of 00.'❑Transportation Shipment 0 by Common Destination 1-5 Carrier Date Cemetery Address ❑ Disinterment Date Cemetery Address ❑ Reinterment 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 t Remains are Shipped, If Other than Above 2 Address W' 0. Permission is hereby granted to dispose of the human remains described above as indicated. Registrar of Vital Statistics W c�J.,�st, �,°�'~J Date Issued 1 /? I /2 (signature) District Number 5 60 i Place G (K2sv`S \,\c , o\) F- I certify that the remains of the decedent identified above were disposed of in accordancean� with this permit on: in Date of Disposition l /ia/it Place of Disposition 'C 4ecru C�w4.ctorit 2` (address) W; ir (section) / , (lot number _ (grave number) c Name of Sexton or Person in Charge of Premises L `+ t" �B��i�' (please pent) WSignature /141)4— Title �aF� �a�� (over) DOH-1555 (02/2004)