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Walsh, Shane Travis NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Shane Travis Walsh Male Date of Death Age If Veteran of U.S.Armed Forces, 12/19/2023 46 Years War or Dates 1— Place of Death Hospital,Institution or IZ City,Town or Village Moreau Town Street Address 13 Pine Road, Moreau Town,New York 12803 0 Manner of Death El Natural Cause Accident ❑Homicide D Suicide nUndetermined El Pending W U II ('Circumstances Investigation W Medical Certifier Name Title C Stephanie Mead NP Address 43 New Scotland Avenue MC7,Albany,New York 12203 Death Certificate Filed Town Of Moreau District Number Register Number City,Town or Village 4562 73 HBurial Date Cemetery,Crematory or Facility Name 12/20/2023 Pine View Crematory Entombment Address - ©Cremation Queensbury Town,New York ▪Donation 0❑Removal Date Place Removed and/or and/or Held ~ Hold Address CO 0 a. Date Point of U)❑Transportation Shipment Q by Common Carrier Destination Date Cemetery Address ElDisinterment Date Cemetery Address El Reinterment Permit Issued to Registration Number Name of Funeral Home M B Kilmer Funeral Home-South Glens Falls 01078 Address 136 Main St,S Glens Falls,New York 12803 Name of Funeral Firm Making Disposition or to Whom t— Remains are Shipped,If Other than Above a Address CC 'Li a. Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 12/20/2023 Registrar of Vital Statistics Brenda Rutter(Electronically Signed) (signature) District Number 4562 Place Town Of Moreau I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: W~ Place ofDis Disposition i i00016:.) b&(��"._. Date of Disposition l2 2f Z� p (address) W NCC (section) 1 (lot number)s.svI, (grave number) Name of Sexton or Person in Charge of mises /p ease print/ W Signature Title DOH-1555(o7/18)p 1 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#