Carlson, Shaun Richard 1--C .:-\\-
4 sNEW YORKSTATE DEPARTMENTOF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Shaun Richard Carlson Male
Date of Death Age If Veteran of U.S.Armed Forces,
08/14/2022 40 Years War or Dates
1... Place of Death Hospital,Institution or
Z City,Town or Village Glens Falls Street Address Glens Falls Hospital
UJ
p Manner of Death a Natural Cause Accident 0 Homicide OSuicide Undetermined Pending
UCircumstances Investigation
WQ Medical Certifier Name Title
Mathew Varughese DO
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 424
BurialH
Date Cemetery,Crematory or Facility Name
08/16/2022 Pine View Crematory
Entombment Address
IJCremation Queensbury Town,New York
Donation
❑Removal Date Place Removed
and/or and/or Held
H Hold Address
0
d Date Point of
N ETransportation
G by Common Shipment
Carrier Destination
ODisinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D Baker Funeral Home 01130
Address
11 Lafayette St,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
1— Remains are Shipped,If Other than Above
5 Address
CC
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 08/15/2022 Registrar of Vital Statistics Megan Wolin(E(ectronicalrySigned)
(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:
1-
Z Date of Disposition gilt?I ZZ Place of Disposition ,�,U <
2 (address)
W
CC CC (section) (lot number) (grave number)
0 Name of Sexton or Person in Charge of P mises /' '�±
z ease print/ r
11.! Signature Title F /� �
DOH-1555(07/18)p i 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#