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Backus, Diane NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex Diane M. BACKUS Female ' Date of Death Age If Veteran of U.S. Armed Forces, - 1 1 /2/2 01 7 70 War or Dates no Place of Death Hospital, Institution or City, Town or Village Lake Luzerne Street Address 1 4 Hill St _ Manner of Death©Natural Cause ❑Accident ❑Homicide ❑Suicide ❑ Undetermined ❑Pending Circumstances Investigation Medical Certifier Name Title AMY Johnson Corinth, NY Address Death Certificate Filed District Number Register Number City, Town or Village Lake Luzerne 5656 1 0 °x}❑Burial Date Cemetery or Crematory ❑Entombment 1 1 /3/201 7 Pine View Crematory Address ar®Cremation Oueensbury, NY Date Place Removed ❑Removal and/or Held and/or Address Hold Date Point of ❑Transportation Shipment by Common Destination Carrier 0-...1 ❑Disinterment Date Cemetery Address .. ❑Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Brewer Funeral Home, Inc. 00211 Address 24 Church St. , Lake Luzerne, NY 12846 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above .-: Address Permission is hereby granted to dispose of the hum re ains des ibed a v as indicated. 41, Date Issued 1 1 /3/201 7 Registrar of Vital Statistic 4"- / �BLI,/ o (signature) District Number 5656 Place Town of Lake Luzerne . I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Date of Disposition 1111111 Place of Disposition f;,4 rJ...' � 4cy-..i (address) • (section) number) 44_ (grave number) � ° Name of Sexton or Person in Charge of Premises //lot i lti SUM (ple se print) !! Signature 4Title TO Ni 4)Y (over) DOH-1555 (02/2004)