Peckman, Shawn M 0111) 7)7
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Male
Shawn M Peckham
Date of Death Age It Veteran of U.S.Armed Forces,
03/30/2022 41 Years War or Dates
Place of Death Hospital,Institution or
ZCity,Town or Village Fort Ann Village Street Address 75 George Street,Fort Ann Village,New York 12827
Manner of Death ❑Natural Cause []Accident []Homicide Suicide []Undetermined Pending
W I Circtunstances Investigation
W Medical Certifier Name 'itle
0 John Aiken Coroner
Address
40 Burquist Road,Fort Ann Town,New York 12827
Death Certificate Filed Village Of Fort Ann District Number Register Number
City,town or Village 5723 1
Burial Date Cemetery,Crematory or Facility Name
04/04/2022 Pine View Crematorium
[]Entombment Address
Cremation Oueensbury Town,New York
Donation
0 Removal Dale Place Removed
and/or andor Held
Hold Address
0
El. Date Point of
to[]transportation
p by Common Shipment
Carrier Destination
Date Cemetery Address
ri Disinterment
Date Cemetery Address
heintermerd
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,It Other than Above
a Address
CC
W
permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 04;04/2022 Registrar of Vital Statistics 1104ara7`PtiniheQtEkitronua/25,St
isigadiurel
District Number 5723 Place Village Of Fort Ann
l certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition 7 7--&ZZ. Placeof Disposition 1/ ` ih'1 J er e/116 vj
2 (ude'res51 _
W
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(set lhm/ (lot number/ (ra ve numbed
8 Name of Sexton or Person in Charg Prenr ees IAA Yr a I J vV oe
Z l (pkese Nr;nl1
W Signature / Title r oa� I
DOH-1555 07/18)p t of 2
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#