Lasell, Denise NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
is Name First Middle Last Sex
Denise A. LaseII Female
Mi Date of Death Age If Veteran of U.S. Armed Forces,
06;26/2016 59 years War or Dates
J Place of Death Hospital, Institution or
ii City, Marx\l eux Saratoga rings Street Address Sara o a Hospital
Manner of Death�latural Cause Accident El Homicide 0 Suicide 11 Undetermined El❑Pending
Circumstances Investigation
uj Medical Certifier Name Title
lamer
MD
Address
211 Church Street Saratoga Springs, NY 12866
Death Certificate Filed District Number Register Number
ffi City, ToX/NM\RIMRX Saratoga Springs 4501 2P1
Ei❑Burial Date Cemetery or Crematory
❑Entombment 06/27/2016 Pineview Crematory
;IMAddress
[Cremation Queensbury, N Y
Date Place Removed
Z❑Removal and/or Held
and/or Address
F" Hold
Date Point of
tr)Li Transportation Shipment
G by Common Destination
Carrier
El Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
i Permit Issued to Registration Number
im Name of Funeral Home Densmore Funeral Home 00448
y> Address
7 Sherman Ave, Corinth; New York 12822
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
IM
lL
Permission is hereby granted to dispose of the human remai ri d abQ "ndicate
Date Issued 06327/2016 Registrar of Vital Statistics •
(signature)
iili District Number 4501 Place Saratoga Springs
1' I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
UI Date of Disposition 6 ta hip Place of DispositionRti)1/4.-1 ‘2 ..,
(address)
Ui
CC (section) (lot number) ,(`. " (grave number)
ti Name of Sexton or Person in Charge of Premises ItzS
Jelf4L-
i• ► `(please print)
iii
Signature g Title
(over)
DOH-1555 (02/2004)