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Shad, Conrad Pierson NEWYORKSTATEDEPARTMENTOFHEALTH ' '� `� 1 " I Bureau of Vital Records Burial - Transit Permit Name First Middle Last Sex Conrad Pierson Shad --- Male Date of Death Age If Veteran of US.Armed Forces, 09/07/2023 80 Years War or Dates F, Place of Death Hospital,Institution or Z City,Town or Village Glens Falls Street Address Glens Falls Hospital pManner of Death a Natural Cause EAccident Li Homicide Suicide Undetermined n Pending ✓ Circumstances Investigation aIU Medical Certifier Name Title Gwendolyn Morris-Dickinson PA 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 433 Burial Date Cemetery,Crematory or Facility Name 09/13/2023 Pine View Crematory Entombment Address ©Cremation Queensbury Town,New York Donation 0❑Removal Date Place Removed and/or and/or Held ~ N Hold Address 0 0. Date Point of N❑Transportation p by Common Shipment Carrier Destination Disinterment 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 Remains are Shipped,If Other than Above 2 Address W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 09/13/2023 Registrar of Vital Statistics Megan Not-in(ECectronicatTy 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: Date of Disposition JJi f/73 Place of DispositionUJ (address) W fl) - ... (section/ (lot number) (grave number) SName of Sexton or Person in Charge of Premises ' L- 4 it Z J (pe print) W Signature Title `R'#n 4 DOH-1555(07h8)p id 2 1 Public Health Law Sec. 4145(2b) Receipt hni:,I is Human remains of delivered on j, 20 P Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License# ; ,,