Lueck, Valerie f 1 # y 5
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
II Name First Middle Last Sex
Valerie L. Lueck Female
Date of Death Age If Veteran of U.S. Armed Forces,
>> 0R/0R/2018 52 years War or Dates
Place of Death Hospital, Institution or
City, Town or Village Town Of Corinth Street Address Wall St
• Manner of Death❑Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
Medical Certifier Name Title
O. Amy Hogan M D
Address
2 Broad Street, Glens Falls, Ny 12801
iiiiiiiii Death Certificate Filed District Number Register Number
infoRty, TowniryxViiikage (nrinth 4553 16
Date Cemetery or Crematory
❑Bu - I . 0R/OR/901 R ._ -12i Pineview Crematory
' Address
Cremation l rlsbu dhl T „,
-Date _ _ __._ _Place Removed_.__
0❑Removal - and/or Held
•t. and/or -Address
ri Hold
OQ - Date Point of
y❑Transportation Shipment.
3 by Common Destination _.
.:'. Carrier
:-:: Date Cemetery Address
❑Disinterment -
.•.`..
Date Cemetery Address
❑Reinterment
Permit Issued to Registration Number
iiM
Name.of Funeral Homcensmore Funeral Home 00448
..... Address
iiiiiiii 7 Sherman Avenue Corinth, NY 12822
liiiii Name of Funeral Firm Making Disposition o_rto Whom
- Remains are Shipped, If Other than Above Densmore Funeral Home
Address
:•• 7 Sherman Avenue, Corinth, NY 12822
»> Permission is hereby granted to dispose of the human re describ ab as indicated.
h; Date Issued 06/07/2018 Registrar of Vital Statistics
(signature)
,,..:
V District Number553 Place Corinth
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
f ;
faDate of Disposition (o I S k Place of Disposition �JL.. fir.,,rr-oe._.
(address)
ILI
t>E (section) 4(lot umber (grave number)
GName,of Sexton or Person in L Charge.of Premises L �ti . _ ►..."'0
I J (please print)
to Signature_ .,.�:�( : I._ ._ Title fiziAtrat
(over)
DOH-1555-(9/98) -