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Shaw, Adam NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Adam John Shaw Male Date of Death Age If Veteran of U.S.Armed Forces, 09/30/2023 41 Years War or Dates i.., Place of Death Hospital,Institution or W City,Town or Village Glens Falls Street Address Glens Falls Hospital p Manner of Death Natural Cause Accident ❑Homicide ESuicide ❑Undetermined Pending W U Circumstances IIIInvestigation QW Medical Certifier Name Title Timothy Murphy Coroner Address 52 Haviland Avenue,Glens Falls,New York 12801 Death Certificate Filed City Of Glens Falls District Number Register Number City,Town or Village 5601 458 Burial Date Cemetery,Crematory or Facility Name 10/06/2023 Pine View Cemetery Entombment _ Address Cremation Queensbury Town,New York nDonation ZO❑Removal Date Place Removed 1 and/or and/or Held N Hold Address 0 O. Date Point of (I)ETransportation p by Common Shipment 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 i... Remains are Shipped,If Other than Above 3 Address W O. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 10/04/2023 Registrar of Vital Statistics !Megan.No('n(E(ectronicalty 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: N Z Date of Disposition Xp.�:a�j Place of Disposition q-1C.vc_t\i<rZ t COve .t'e y� / / 04 (address) / CLt Oction)�`� llotni )a ber (grave number) gName of Sexton or Person in Charge of Premi Oar)i'e Ea' 4' Z (please print) W Si nature S Rjn--7y1Aen/— g Title 1 DOH-1555(07/18)p 1 of 2 Public Health Law Sec.4145(2b) 013000 Receipt Human remains of delivered on , 20 : ✓Vv" ne View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License# TUCKER \` Owner ( „ Dorothy Tucked Address Plot 27 Park Ave. Ft. Edward, NY 12828 Horicon 16I Phone # Lot # 518-746-7136 16 I Deed # Date 4411 10-2-23 Cost Foundation Y - N $800.00 Location West-Condon South-Arevaido North-Vacant East-Hermance Remarks I ACKNOWLEDGE THE RECEIPT OF THE RULES AND REGULATIONS OF THE PINE VIEW CEMETERY: SIGNATURE: � DATE: ‘C-3'-6-'-a: SIGNATURE: DATE: Record of Interments 1,A rn��aw• 10 Le 6 2 7 3 8 4 9 5 10 Corld©n A G L. T 0 E SHAW NAME Adam Shaw Age: 41 Lot Owner: Dorothy Tucker Lot# Horicon 16 I Grave# 1 Case: Concrete Died: 9.3 0.2 3 Interred: 1 0.6.2 3 Funeral Home: Carleton FH Cemetery: Pine View