Dalaba, Lorraine r 1 1
NEW YORK STATE DEPARTMENT OF HEALTH Q)tO
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Lorraine E. Dalaba Female
Date of Death Age If Veteran of U.S. Armed Forces,
December 9,2011 86 War or Dates
Place of Death Hospital, Institution or
Z City, Town or Village Glens Falls Street Address Glens Falls Hospital
pManner of Death X Natural Cause I 'Accident Homicide Suicide Undetermined Pending
w Circumstances Investigation
W Medical Certifier Name Title
0 Paul Bachman MD
Address
HlII3N,Warrensburg,NY 12885
Death Certificate Filed District Number Reg_ist Iber
City, Town or Village Glens Falls,NY 5601 JJ
❑Burial Date Cemetery or Crematory
Entombment December 12,2011 Pine View Crematory
El Address
❑X Cremation Quaker Rd.,Queensbury,NY 12804
Date Place Removed
Z I I Removal and/or Held
and/or Address
F" Hold
U)
O Date Point of
NTransportation Shipment
a by Common Destination
Carrier
Disinterment Date Cemetery Address
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
H Remains are Shipped, If Other than Above
2 Address
w
a Permission is hereby granted to dispose of the human remains desc "bed a as " c ted.
Date Issued /�/j mil' Registrar of Vital Statistics
(signature)
District Number 5601 Place Glens Falls,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I—
w Date of Disposition oiL(31 Nit Place of Disposition 2,14(''II /�.) ( ndit1
(address)
w
CO
re (section) (lot number) (grave number)
p /trotName of Sexton or Person in Charge Premises Sthr''t,11'
z (please print)
w Signature4 Title Clitektk.1.0(-
(over)
DOH-1555(02/2004)