LaPoint, Marilyn f ). 7#NEW YORK STATE DEPARTMENT OF HEALTH , / 610.
U
�
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Marilyn M. LaPoint Female
Date of Death Age If Veteran of U.S. Armed Forces,
07/30/2016 83 yrs. War or Dates no
11114 Place of Death - Hospital, Institution or
City, Town or illage Hudson Falls Street Address 82 Oak St.
Manner of Death Natural Cause Accident Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Address
/ / c, qgY NO., 4'UE.47vsvitIRy,,s/y/,/vd°'F
Death Certificate Filed District Number Register Number
iigi City, Town o�llagj Hudson Falls 5 7Q 6 i
O
Date Cemetery or Crematory
❑Burial g-0 / - 20/ PineView Crematorium
Address
laCremation Town of Queensbury, NY. 12804
FDate Place Removed
0 Removal and/or Held
... and/or Address
=-7 Hold
0
0 Date Point of
N❑Transportation Shipment
a by Common Destination
Carrier
Hi
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
iiiiiii Permit Issued to Registration Number
Oi Name of Funeral Home Mason Funeral Home 01 1 1 7
iai
Address
P.O. Box 277, Fort Ann, NY. 12827
`<- Name of Funeral Firm Making Disposition or to Whom
w" Remains are Shipped, If Other than Above
M Address
4
Permission is hereby granted to dispose of the human rema' described above as indicated.
iiii Date Issued 08/01 /1 6 Registrar of Vital Statistics C, Qsa-4 -e----k_____
(signature)
District Number:J 7
Place Village of Hudson Falls, NY.
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
II V ` 7
Z..Date of Disposition g' I t'6 Place of Disposition ��OZ./ r'hwa'` .--.
W (address)
CO
CC (section) lot number) cc (grave number)
GName of Sexton or Person in Cha a of Premises Z. ,i/.4441
(please print)
t1. Signature (f Title criol'ip(
(over)
DOH-1555 (9/98)