Bolton, Shirley Nancy f
NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Shirley Nancy Bolton Female
Date of Death Age If Veteran of U.S.Armed Forces,
09/15/2021 85 Years War or Dates
Place of Death Hospital,Institution or
W City,Town or Village Glens Falls Street Address Glens Falls Hospital
tp Manner of Death XI Natural Cause Ei Accident. Homicide El SuicideUndetermined Pending
Circumstances Investigation
LU Medical Certifier Name Title
Abigail Macomber PA
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Glens Falls 5601 402
ElBurial Date Cemetery,Crematory or Facility Name
09/16/2021 Pine ViewCrematorium
ElEntombment Address
ElCremation Queensbury Hamlet,New York
ElDonation
Removal Date Place Removed
and/or and/or Held
N Hold Address
O
Q. ❑ Date Point of
t/) Transportation
p by Common Shipment
Carrier Destination
Disinterment
Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Barton-Mcdermott Funeral Home Inc 00141
Address
9 Pine St,Chestertown,New York 12817
Name of Funeral Firm Making Disposition or to Whom
F. Remains are Shipped,If Other than Above
2 Address
CC
W
a' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 09/16/2021 Registrar of Vital Statistics Men Andrew Curtis(E&ctronica1lySigned)
(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 9/i Cj ) Place of Disposition r j v Z,W G(64,q krr}'
(address)
W
(section) (lot number) (grave number)
gName of Sexton or Perso in Charge of Premises JeP sty Sp ccs
Z (please print)
W Signature i//V a/21 Title GrG" o
DOH-1555(07/18)p 1 of 2
fl15i 8
Public Health Law Sec. 4145(2b)
Receipt
Human remains o . _ ' ->/delivered on ( 20
r ,
Pine View Cemetery Representifig the funeral home named on burial,pernut
Official Funeral Directors Reg.or License#`