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Payinda, Laura NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit ' : Name First Middle Last Sex Laura Rosa Payinda Female Date of Death Age If Veteran of U.S. Armed Forces, November 17, 2016 82 War or Dates Place of Death Hospital, Institution or City, Town or Village Glens Falls Street Address Glens Falls Hospital Manner of Death Natural Cause D Accident 0 Homicide 0 Suicide n Undetermined Pending Circumstances Investigation • Medical Certifier Name Titl Michael Fuller Address 100 Park St,Glens Falls,NY 12801 Death Certificate Filed District Number 5 t Register Number City, Town or Village rjg i ❑Burial Date Cemetery or Crematory November 21, 2016 Pine View Crematorium ❑Entombment Address ©Cremation 51 Quaker Road, Queensbury,NY 12804 Date Place Removed ZZ ❑Removal and/or Held and/or Address L Hold U) 0 Date Point of u) Transportation Shipment p by Common Destination Carrier ❑Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Regan Denny Stafford Funeral Home 01443 `' Address 53 Quaker Road, Queensbury,NY 12804 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 human remains described above as indicated. Date Issued i + I I 12c)i/ Registrar of Vital Statistics W (signs re)r. " .,; District Number 5 ( Place 6 c S Eck 1 \ , If y' I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: W Date of Disposition /IJzi lit, Place of Disposition "P �n itt . G f1`►nw'ior,-, (address) Cl) r (section) ,/q(lot number) r (grave number) 0 G Name of Sexton or Person in Char a of Premises (<ris i tna/t'f Z �� /� (pl ase print) W Signature Gt Title �tzt►ill�CD(ti-Ot1 (over) DOH-1555(02/2004)