VanOrman, Leota 41 tic/
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
T Name First Middle Last Sex
Leota I VanOrman Female
e'. Date of Death Age If Veteran of U.S. Armed Forces,
September 29, 2011 84 I War or Dates
Place of Death Hospital, Institution or
Z' City, Town or Village Fort Edward Street Address Fort Hudson Nursing Home
tli
cf; Manner of Death I]Natural Cause Accident piHomicide n Suicide Undetermined Pending
b# Circumstances Investigation
U Medical Certifier Name Title
Fi Philip Gara,MD
Address
327 Broadway,Ft.Edward,NY 12828
Death Certificate Filed District Numbe Register Number
City, Town or Village Ft.Edward 5?S I s(x,
❑Burial Date Cemetery or Crematory
September 30, 2011 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
Z I I Removal and/or Held
H and/or Address
Hold
0 Date Point of
co_a.
Transportation Shipment
O by Common Destination
Carrier
Disinterment Date Cemetery Address
n Reinterment Date Cemetery Address
I
Permit Issued to Regan& Denny Funeral Home I Registratioaiber
• : Name of Funeral Home
uaker Road, Queensbury,NY 12804
_ Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
iii
,>L Permission is h re granted to dispose of the human re ins described above s indicated.
u Date Issued i Registrar of Vital Statisti
(signature)
, District Number 5 2 Place Ft.Edward
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition (V—i( ti Place of Disposition inQQs p,...j C1`-e,ntc4nr,'u:in
(address)
W
CO
d' (section)^ (lot number) (grave number)
O Name of Sexton or Person in Char a of Premises
Z 9 ttratio 2tt., ld<
(please print)
uJ Signature Title Crernt'ia� 14Sg� .
(over)
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