Shelton, Lawrence Raymond 12z-7
NEW YORK STATE DEPCRTMENTOF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Lawrence Raymond Shelton Male
Date of Death Age If Veteran of U.S.Armed Forces,
11/20/2020 68 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Lake George Town Street Address 18 Old State S Road,Lake George Town,New York 12845
W
tp Manner of Death 0Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
CI John Stoutenburg MD
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Lake George 5651 6
ElBurial Date Cemetery,Crematory or Facility Name
11/23/2020 Pine View Crematory
❑Entombment Address
X❑Cremation QueensbUljr;New York
0 Donation
O Removal Date Place Removed
and/or and/or Held
N Hold Address
0
d Date Point of
N LiTransportation
Q by Common Shipment
Carrier Destination
Disinterment
Date Cemetery Address
Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
1— Remains are Shipped,If Other than Above
2 Address
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11/23/2020 Registrar of Vital Statistics Patricia ICAfclattneySclrurtergYectronicatySrgne4
(signature)
District Number 5651 Place Lake George, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z Date of Disposition 1i124 I Z Zit
� Place of Disposition
W (address)
W
NEr (section) (lot number) (grave number)
Name of Sexton or Person in Charge of P ises Ds^"
Z ( easese print)
W Signature Title Clw»it L
DOH-1555(o7/18)p t of 2
Public Health Law Sec. 4145(2b) 014219
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#