LaPoint, Terri 1
NEW YORK STATE DEPARTMENT OF HEALTH 5 74
Vital Records Section Burial - Transit Permit
/' ,
Name First Middle Last Sex
Terri Lynn LaPoint Female
Date of Death Age r If Veteran of U.S. Armed Forces,
August 5,2016 62 War or Dates
F- Place of Death Hospital, Institution or
Z ,City.,Iown or Vif+age Jackson Street Address 250 County Route 61
p Manner of Death X Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
W Medical Certifier Name Title
G Michael Sikirica MD
Address
50 Broad Street,Waterford,NY 12118
Death Certificate Filed District Number Register Number
,Eity, Town or4difMge Jackson 5761
❑Burial Date Cemetery or Crematory
❑Entombment August 12,2016 Pine View Crematorium
Address
❑x Cremation Queensbury, NY
Date Place Removed
Z I Removal and/or Held
and/or Address
H Hold
U)
O Date Point of
N Transportation Shipment
a by Common Destination
Carrier
Disinterment Date I Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home,Inc. 00281
Address
68 Main Street,Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
i- Remains are Shipped, If Other than Above
2 Address
a
Permission is hereby granted to dispose of the human remains described ove as
Date Issued 8/8/2016 Registrar of Vital Statisti
(signat e
District Number 5761 Place Jackson,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w Date of Disposition 4(11(1i Place of Disposition Paw,, a c4,_,
W (address)
N
0 (section) (lot number) (grave number)
pName of Sexton or Person in Charge of Premises >tif L.r StR
Z please print)
W
Signature it Title Cfq ft
(over)
DOH-1555 (02/2004)