White, Shirley Ann 2 1L
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NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Shirley Ann White Female
Date of Death Age If Veteran of U.S.Armed Forces,
03/07/2021 86 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address The Pines At Glens Falls Center For Nursing&Rehabilitation
W Manner Death Pending
G �, � Natural Cause �Accident �Homicide �Suicide �Undetermined
W Circumstances Investigation
W Medical Certifier Name Title
Kenneth France MD
Address
170 Warren St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 136
0 Burial Date Cemetery,Crematory or Facility Name
03/10/2021 Pine View Crematory
❑Entombment Address
X❑Cremation Queensbury Town,New York
Donation
ZO Removal Date Place Removed
and/or and/or Held
Hold Address
0
0.. Date Point of
U) Li Transportation Shipment
by Common
Carrier Destination
Date Cemetery Address
❑ Disinterment
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D Baker Funeral Home 01130
Address
11 Lafayette St,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
1— Remains are Shipped,If Other than Above
Address
CC
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 03/10/2021 Registrar of Vital Statistics o6ert./?nri-reu,Curtis gkctronicall Signed)
(signature)
District Number 5601 Place Glens Falls, 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 3 I IZ I Zi Place of Disposition IL. i_-
W (address)
W
CC (section) (tottimbeer) (grave number)
Name of Sexton or Person in Charge of Pre ' es �''��tT
(please print
W Si gnature Title 64 "C
DOH-1555(07/18)p 1 of 2
I
014C32
Receipt
Human remains of delivered on 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#