Grovenburg, Laurie NEW YORK STATE DEPARTMENT OF HEALTH , _ ..
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Laurie Ann Grovenburg Female
Date of Death Age If Veteran of U.S. Armed Forces,
May 23,2011 42 War or Dates
1►r Place of Death Hospital, Institution or
Z City, Town or Village Queensbury Street Address One Manor Drive, Apt. D
{ Manner of Death g Natural Cause I l Accident n Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
0 Aqeel Gillani
Address
CR Wood Cancer Center, 102 Park St.,Glens Falls,NY 12801
Death Certificate Filed District Number Register Number
City, Town or Village Queensbury 5657 9
❑Burial Date Cemetery or Crematory
Pine View Crematory
0 Entombment Address
®Cremation Quaker Rd., Queensbury,NY 12804
Date Place Removed
Z I I Removal and/or Held
and/or Address
H Hold
cn
O Date Point of
w Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
I Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Alexander-Baker Funeral Home 00035
Address
3809 Main Street,Warrensburg,NY 12885 _
�, Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
W1
a` Permission is here y granted to dispose of the humarains des ribed above as indicated.
Date Issued 1c Registrar of Vital Statistics rim` _
\ nature)
District Number 5657 Place Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z +' `
w Date of Disposition (.-�-(I Place of Disposition _Pint L.64 Cirm.c¢orcv&.
W (address)
co
is (section) 4(4
A(lot nun)ber) (grave number)
pName of Sexton o erson in Ch ge of Premises } t.. S,gItt
Z J (please print)
WL._ _`-
Signature Title �'�INrY^K/►L
(over)
DOH-1555 (02/2004)