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Shaw, Roger L IAA - z�s- NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Roger L Shaw Male Date of Death Age If Veteran of US.Armed Forces, 02/26/2024 76 Years War or Dates 1968-70 F Place of Death Hospital.Institution or Z City,Town or Village Thurman Town Street Address 1272 River Road,Thurman Town,New York 12885 ILJ p Manner of Death Natural Cause ❑Accident El Homicide El Suicide Undetermined El Pending W V Circumstances Investigation WC) Medical Certifier Name Title Curtis Gedney MD Address 454 Glen Street,Glens Falls,New York 12801 Death Certificate Filed Town Of Thurman District Number Register Number City,Town or Village 5659 2 Burial Date Cemetery,Crematory or Facility Name UMW 02/29/2024 Pineview Crematory Entombment Address ©Cremation Queensbury Town,New York DDonation 0❑Removal Date Place Removed and/or and/or Held F Hold Address (13 0 O. Date Point of N)❑Transportation p by Common Shipment Carrier Destination Date Cemetery Address ❑Disinterment Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Densmore Funeral Home Inc 00448 Address 7 Sherman Ave,Corinth,New York 12822 Name of Funeral Firm Making Disposition or to Whom F Remains are Shipped,If Other than Above 2 Address CC W n' Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 02/28/2024 Registrar of Vital Statistics Cynthia R.Hyde(Electronically Signed) (signature/ District Number 5659 Place Town Of Thurman I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: IF- Z Date of Disposition 21111211 Place of Disposition ? ,cf,, ) (OA�1r�i C i (address) W Cl)CC /section) (iat number) (grave number) 8 Name of Sexton or Person in Charge of re es i ,,, '-,, ".41 Z please prkt W Signature Title CPe^1A.M.( DOH-1555(07/18)p i 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 1 Official Funeral Directors Reg.or License#