Shippee,Irving M Jr. GO
NEWYORKSTATEDEPARTMENTOFHEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Irving M Shippee Jr Male
Date of Death Age If Veteran of U.S.Armed Forces,
03/23/2022 57 Years War or Dates
H Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
UJ
Q Manner of Death II NaturaL Cause Accident Homicide 0Suicide Undetermined ElPending
UJ
0 Circumstances / 'Investigation
WD Medical Certifier Name Title
Scott Miller PA
Address
100 Park St,Glens Falls,New York 12801
Death Certificate Filed City Of Glens Falls District Number Register Number
City,Town or Village 5601 179
BurialE
Date Cemetery,Crematory or Facility Name
03/25/2022 Pineview Crematory
Entombment Address
Cremation Queensbury Town,New York
DDonation
O► I Removal Date Place Removed
and/or and/or Held
~ Hold Address
N
0
fl- Date Point of
U)ElTransportation
p by Common Shipment
Carrier Destination
Date Cemetery Address
nDisinterment
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Densmore Funeral Home Inc 00448
Address
7 Sherman Ave,Corinth,New York 12822
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped,If Other than Above
a Address
Q
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 03/25/2022 Registrar of Vital Statistics Megan Nolin(Electronically Signed)
(signature)
District Number 5601 Place City Of Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I—
Z Date of Disposition 3-26-2 ztPlace of Disposition --Pi`aC Of e,,J Creerki,4, -s
2 (address)
W
U)
Q (section) (lotg number (grave number)
0
Name of Sexton or Person in Charge f Premise ! 0 'ymo,i) L
Z / (please print)
W Signature L Title 0rersld(
DOH-1555(07/18)p 1 of 2
I
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#