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McKernon, Shirley Louise It NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Shirley Louise McKernon Female Date of Death Age If Veteran of U.S.Armed Forces, 01/13/2021 100 Years War or Dates F Place of Death Hospital,Institution or W City,Town or Village Granville Village Street Address Granville Center for Rehabilitation and Nursing p Manner of Death ©Natural Cause Accident Homicide Suicide ❑Undetermined 0 Pending W Circumstances Investigation U W Medical Certifier Name Title Thomas Kandora MD Address 17 Madison St,Granville Village,New York 12832 Death Certificate Filed District Number Register Number City,Town or Village Granville Village 5725 05 ❑Burial Date Cemetery,Crematory or Facility Name 01/15/2021 Pine View Crematorium ❑Entombment Address X❑Cremation Queensbury Town,New York ❑Donation O Removal Date Place Removed and/or and/or Held N Hold Address 0 d. Date Point of Cl) ❑Transportation p by Common Shipment Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home Inc 00281 Address 68 Main Street,P.O.Box 67,Hudson Falls,New York 12839 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped,If Other than Above g Address CC W O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 01/15/2021 Registrar of Vital Statistics qZicfiarcfMerts(E(ectronicaCTy Signed) (signature) District Number 5725 Place Granville Village, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: WDate of Disposition I//i apa/Place of Disposition Pt: Jt�Ll �hGl►L G-►a' g (address) W CC (section) (lot number) (grave number) Rl r Name of Sexton or Person in Char a of Premis f f�O^74 E. � � (please print) ILL Signature Title DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) I�1_4 419 Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#