Lasell, Emily E. NEW YORK STATE DEPARTMENT OF HEALT "� Burial - Transit Permit
Bureau of Vital Records
Name First Last Sex
Emily E Lasell 7Female
Date of Death Age Veteran of U.S.Armed Forces,
05/04/2020 84 Year ar or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Queensbury Town Street Address The Stanton Nursing And Rehabilitation Centre
W Manner of Death
�
W Natural Cause �Accident �Homicide �Suicide �Undetermined �Pending
V Circumstances Investigation
0 Medical Certifier Name Title
Wendy Steinhacker PA
Address
152 Sherman Ave,Queensbury Town,New York 12801
Death Certificate Filed District Number Register Number
City,Town or Village Queensbury 5657 92
❑Burial Date Cemetery,Crematory or Facility Name
05/06/2020 Pineview Crematory
Entombment Address
0 Cremation Queensbury Town,New York
Donation
0 ❑Removal D#te Place Removed
and/or and/or Held
H N Hold "Address
O
d Date Point of
U) ❑Transportation
p by Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
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
Remains are Shipped,If Other than Above
Address
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 05/05/2020 Registrar of Vital Statistics Caroline Hildegarde Barber(Electronically Signed)
/signature/
District Number 5657 Place Queensbury, New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
F- rr � i�
Z Date of Disposition J �� ('l��lace of Disposition 4.uL r--
W
2 /address)
W
N (section) // /iotnumber (grave number/
O Name of Sexton or Person in Charge of Premises A.t
tpl—
z n
z /pi a print/
W
Signature ifs Title 114'fi
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b) 10 3 7 1
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#