Shangraw, Jr. Walter NEW YORK STATE DEPARTMENT OF HEALTH ' 57,
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Walter F. Shangraw,Jr. Male
Date of Death Age If Veteran of U.S. Armed Forces,
December 7, 2012 81 War or Dates
4 Place of Death Hospital, Institution or
Z° City, Town or Village Queensbury Street Address 11 Chelsa Place
Hi
Manner of Death X Natural Cause 1 !Accident Homicide Suicide Undetermined Pending
til Circumstances Investigation
, Medical Certifier Name Title
T Coppens
Address
sm 3 Irongate, Glens Falls,NY 12801
:a Death Certificate Filed District Number Regis er Number
City, Town or Village Queensbury 5657 1 �'"
❑Burial Date Cemetery or Crematory
II Entombment December 10, 2012 Pine View Crematorium
Address
❑x Cremation Quaker Road, Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
Q and/or Address
H Hold
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0 Date Point of
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u) Transportation Shipment
p by Common Destination
Carrier
(Disinterment Date Cemetery Address
n Reinterment
Date Cemetery Address
I
: i:; Permit Issued to Registration Number
:_„ Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
x.: Address
407 Bay Road, Queensbury, NY 12804
.. Name of Funeral Firm Making Disposition or to Whom
lw+; Remains are Shipped, If Other than Above
E. Address
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Permission is hereby granted to dispose of the human mains described jbbove s i dicated.
Date Issued Ia.) )01a.)) Registrar of Vital Statistics /
(signature)
District Number 5657 Place Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
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ui Date of Disposition it. (3- aPlace of Disposition �V�ru C �,vrr.
III (address)
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(section) dkriCT-44,-
(lot number) (grave number)
p Name of Sexton or Person in Charge of Premises woilt"
Z (please print)
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Signature4L...., Title Cav1 tTQQi
(over)
DOH-1555(02/2004)