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Buckley,Shelly Ann . ,113 NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Shelly Ann Buckley Female Date of Death Age If Veteran of U.S.Armed Forces, 06/03/2021 59 Years War or Dates Place of Death Hospital,Institution or W City,Town or Village Glens Falls Street Address Glens Falls Hospital p Manner of Death ©Natural Cause Accident Homicide I=1 Suicide ❑Undetermined Ei Pending Circumstances Investigation WMedical Certifier Name Title Julian Marynczak PA Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Glens Falls 5601 234 0 Burial Date Cemetery,Crematory or Facility Name 06/07/2021 Pine View Crematorium 0 Entombment Address IDCremation Queensbury Town,New York ❑Donation 6 ❑Removal Date Place Removed and/or and/or Held H Hold Address rA 0 O. Date Point of Cl) u Transportation by Common Shipment Carrier Destination El 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 S Address CC W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 06/07/2021 Registrar of Vital Statistics gp6ertAndrew Curtis(ECectronicalTy 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: IF- 'I ,� I W Date of Disposition r0 1'1 1 vl Place of Disposition 2 (address) W CCCC (section) lot number) (grave number) Name of Sexton or Person in Charge of Prem. es nw (please Intl W 6.41404 Signature Title �� DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) 01 fli340 Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#