Shook, Wayne E Ul—' "—l'i
NEW YORK STATE DEPARTMENT OF HEALTH
Bureau of Vital Records Burial - Transit Permit
Name First Middle Last Sex
Wayne E.Shook Male
Date of Death Age If Veteran of U.S.Armed Forces,
07/14/2022 72 Years War or Dates
F- Place of Death Hospital,Institution or
Z City,Town or Village Bolton Town Street Address 27 Stewart Avenue,Bolton Town,New York 12814
pManner of Death II Natural Cause Accident []Homicide Suicide Undetermined ri Pending
UCircumstances Investigation
P Medical Certifier Name Title
Lynn Keil PA
Address
1340 State Route 9,Lake George Town,New York 12845
DeaRth Certificate Filed Town Of Bolton District Number Register Number
City,Town or Village 5650 4
Burial Date Cemetery,Crematory or Facility Name
07/16/2022 Pine View Crematory
Entombment Address
, VECremation Queensbury Town,New York
Donation
❑Removal Date Place Removed
and/or and/or Held
H Hold Address
N
0
Cl. Date Point of
CO Transportation
p by Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
ElReinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Alexander Baker Funeral Home 00037
Address
3809 Main St,Warrensburg,New York 12885
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped,If Other than Above
5 Address
a:
W
O. Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 07/15/2022 Registrar of Vital Statistics Jodi Petteys(E(ectronically Signed)
(signature)
District Number 5650 Place Town Of Bolton
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Ik-.
Z Date of Disposition L Place of Disposition `
Iw 7—J�—?yz P �,� ��eKI C'ne014-4,>
W (address
N
CC (section) (lot numb ) (grave number)
0 Name of Sexton or Person in Ch a of re ' es i.1Y'NIOn2D
Z Qe*C4
e print)
MISi nature
gcep( ` Title QQeS r
DOH-1555(o7/t8)p 1 of 2 1
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#