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Lajeunesse, Scott f NEW YORK STATE DEPARTMENT OF HEALTH 1/9/ Vital Records Section Burial - Transit Permit Name sLiifst k i d/Riond Lajeunstse AV Date of Death A e If Veteran of U.S. Armed Forces, IJ/03/2011 41 ,ears War or Dates Place of Death Hospital, Institution or C vWr Wi llage ohaes Street Addre - Agnes Cemetery Manner of Death rCi Natural Cause El Accident El Homicide El Suicide riUndetermined �Pending W Circumstances Investigation ut Medical Certifier Name Title Hermandi Thomas told 11 :f 2 fase street, .4i bany, N Y, 12207 Death Certificate Filed District Number Register Number Ct'' , ut�r lIageC©hoes 102 33 lik DBurial Date Cemetery or Crematory 10/04/2011 Pine 'View C..rematorg, ❑Entombment Address `ski OCremation Oueensbury, NY Date Place Removed Removal and/or Held and/or Address E Hold Date Point of �` Transportation❑ p Shipment C by Common Destination Carrier ''"` Q Disinterment Date Cemetery Address `'`'Q Reinterment Date Cemetery Address Permit Issued to Reggistration Number Name of Funeral Hoty'nard D. Baker 011311 Address II 11 Lafayette St Cueensbury, f•ly 12804 iiM Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above ' Address ir Lu '` Permission is hereby granted to dispose of the human remains described above as indicated. Date Issuee `8412011 Registrar of Vital Statistics X ME (signature District Numlb@V Place Cohoes Lii I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: ut k l .he Date of Disposition (D .6._ i i Place of Disposition � t./,`6; (�; ri�1 e,w ur,'0,,r iL I (address) CO CC (section) (lot number) (grave number) 12 Name of Sexton or Person in Ch '7 X .z I ge of Premises ( �m o u ri e 2 ��/ r (please pri t) Signature 4.c nv I1h�,, Title Ce'?vniAor7 ►455 (over) DOH-1555 (02/2004)