Graves, Shirley NEW YfNRK STATE DEPARTMENT OF HEALTH �;
Vital Records Section_ ___. __ __ .__ _ Burial - Transit Permit
pi Name First Middle Last Sex
Shirley M Graves 1 Female
i
4.,t Date of Death ' Age If Veteran of U.S. Armed Forces,
08/16/2018 79 Years War or Dates
Place of Death Hospital, Institution or
City, Town or Village Glens Falls Street Address Glens Falls Hospital
Manner of Death X Natural Cause [ ]Accident El Homicide j Suicide l_ Undetermined 1 Pending
Circumstances Investigation
'0' Medical Certifier Name Title
Jennifer Donovan DO
Address -- ---------------�
100 Park St,Glens Falls,New York 12801
- Death Certificate Filed District Number TRegister Number
City, Town or Village Glens Falls 5601 [ 392
tP_Burial
I Date Cemetery or Crematory
i 08/16/2018 PineView Crematorium
'; i Entombment—
* Address
os Cremation Queensbury Town, New York
Date T Place Removed
6 1 Removal I and/or Held
—'and/or Address
is Hold
Date —1 Point of
n-1 Transportation Shipment
by Common Destination
Carrier
01, Disinterment
Date Cemetery Address
Reinterment
Date Cemetery Address
Permit Issued to Registration Number
7 Name of Funeral Home Mason Funeral Home 01117
- Address
18 George St Po Box 277,Fort Ann, New York 12827-0277
Name of Funeral Firm Making Disposition or to Whom
k" Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human remains described above as indicated.
s
W- Date Issued 08/16/2018 Registrar of Vital Statistics Ro6ertA Curtis(E(ectronica((y Signed)
IV
(signature)
km2k J District Number 5601 Place Glens Falls, New York
certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Te Date of Disposition gliud Place of Disposition -i��i+� , ,-rii
(address)
(section) (lot number) (grave number)
—'4 Name of Sexton or Person in Charge of Premises ram, ,e/' ,4 �
(please pr t)
Signature '+✓t Title r aL
(over)
DOH-1555 (02/2004)