Shangraw, Martha K. NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Martha K.Shangraw Female
Date of Death Age If Veteran of US.Armed Forces,
06/28/2021 90 Years War or Dates
i., Place of Death Hospital,Institution or
WCity,Town or Village Queensbury Town Street Address 39 Longview Drive 226,Queensbury Town,New York 12804
p Manner of Death ❑X Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined 0 Pending
W Circumstances Investigation
U W Medical Certifier Name Title
a Jeremy Di Bari MD
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed District Number Register Number
City,Town or Village Queensbury 5657 134
❑Burial Date Cemetery,Crematory or Facility Name
07/01/2021 Pine View Crematory
❑Entombment Address
X❑Cremation Queensbury Town,New York
❑Donation
Date Place Removed
Removal and/or Held
H and/or
N
Hold Address
0
Date Point of
N El Transportation Shipment
G by Common
Carrier Destination
0 Disinterment
Date Cemetery Address
Date Cemetery Address
0 Reinterment
Permit Issued to Registration Number
Name of Funeral Home Singleton Sullivan Potter Funeral Home 01596
Address
407 Bay Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
p- Remains are Shipped,If Other than Above
Address
Cr
W
0-
Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 07/01/2021 Registrar of Vital Statistics Carolnexldegard Bar6er(EkctronicallySigne4
(signature)
District Number 5657 Place Queensbury, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WZ -,L--a Date of Disposition � - .c>;-{ Place of Disposition p,7,e. V;014i Gl'6r+4G(�y
(address)
2
Ill
Cl) (section) (lot number) (grave number)
O Name of Sexton or Person in Charge of Premises ,CEN1-e'Y Sp '.r- ij
Z (please print)
W Signature A/10
.� Title C—,fvTh`;/ar
DOH-1555(07/18)p 1 of 2
i
C
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#