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Case, Shirley Marie
0 NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Shirley Marie Case • Female Date of Death Age If Veteran of U.S.Armed Forces, 07/18/2023 87 Years War or Dates Place of Death Hospital,Institution or Z City,Town or Village Fort Edward Town Street Address Fort Hudson Nursing Center Inc W Manner of Death Undetermined []Pending Natural Cause []Accident Homicide Suicide W I 'Investigation Investigation W Medical Certifier Name Title CI Carrie Miron PA Address • 319 Broadway,Fort Edward Town,New York 12828 Death Certificate Filed Town Of Fort Edward District Number Register Number City,Town or Village 5755 64 Burial Date I Cemetery,Crematory or Facility Name 07/20/2023 I Pine View Crematorium Entombment _ Address ©Cremation Queensbury Town,New York Donation Z Removal Date Place Removed and/or and/or Held H Hold Address LO O. Date Point of Cl)❑Transportation Shipment Q by Common Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address 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 1_ Remains are Shipped,If Other than Above 3 Address It W O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 07/20/2023 Registrar of Vital Statistics Aimee G Mahoney(E(ectronicatfy Signed) (signature) District Number 5755 Place Town Of Fort Edward I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: I— //7,, W Date of Disposition 7 IZj 1213 Place of Disposition �,�c : _.... 2 (address) W Cl)CC (section) Art(lot number) (grave number) • Name of Sexton or Person in Charge of Pr s ttf f Z (pse print) W Signature Title rr / t DOH-1555(07/18)p 1 of 2 1 1 1 O '�s 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#