Lobner, Shane E w`t
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#
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Shane E Lobner Male
Date of Death Age If Veteran of U.S.Armed Forces,
01/14/2023 56 Years War or Dates
Place of Death Hospital,Institution or
City,Town or Village Glens Falls Street Address Glens Falls Hospital
pManner of Death ID Natural Cause Accident Ei Homicide ESuicide FlUndetermined riPending
W Circumstances Investigation
W Medical Certifier Name Title
CI Jeremy Di Bari MD
Address
9 Carey Road,Queensbury Town,New York 12804
Death Certificate Filed City Of Glens Falls District Number Register Number
City,Town or Village 5601 35
Burial Date Cemetery,Crematory or Facility Name
01/19/2023 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
0ā¯‘Removal Date Place Removed
and/or and/or Held
p Hold Address
et
a Date Point of
(0ā¯‘Transportation Shipment
S by Common
Carrier Destination
o
Disinterment
Date Cemetery Address
Date Cemetery Address
El Reinterment
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to I.. Remains are Shipped,If Other than Above
S Address
CC
W
EL Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 01/19/2023 Registrar of Vital Statistics Megan Wain(ECectronicaffySigned)
(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:
Z4W Date of Disposition Zy(13 Place of Disposition IL
2 (address)
W
N (section) 4 (lot number) `t (grave number)
CC0 Name of Sexton or Person in Charge of Premises
Z zi
(dlease print)
W Title c mH0C
Signature
DOH-1555(07/18)p 1 of 2