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LaMora, Lois NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit Name First Middle Last Sex Lois Marie LaMora Female r Date of Death Age If Veteran of U.S. Armed Forces, December 7, 2016 74 War or Dates n/a Place of Death Hospital, Institution or z. City, Town or Village Fort Edward Street Address Fort Hudson Nursing Home Manner of Death I XI Natural Cause n Accident n Homicide n Suicide n Undetermined Pending .r€= Circumstances Investigation I ` Medical Certifier Name Title sf; Address .f k Death Certificate Filed District Number Regis er JVumber r_r.: l t City, Town or Village Fort Edward, NY 5755 ©Burial Date Cemetery or Crematory December 12,2016 Pine View Cemetery ❑Entombment Address ❑Cremation Quaker Road, Queensbury,NY 12804 Date Place Removed ZZ n Removal and/or Held and/or Address H Hold 0 Date Point of Di ❑Transportation Shipment p by Common Destination Carrier Disinterment Date Cemetery Address n Reinterment Date Cemetery Address .g Permit Issued to Registration Number 61 Name of Funeral Home Regan Denny Stafford Funeral Home 01443 ;= Address _': 53 Quaker Road, Queensbury,NY 12804 Name of Funeral Firm Making Disposition or to Whom 1Remains are Shipped, If Other than Above Address Permission is her by anted to dispose of the human r ins described above as i dicated. v- Date Issued /� /�Q Registrar of Vital Statistic ` p_ r!�n l a �� e& ::, ,� (signature) : >:>:r:; District Number5-76-r_ Placea]-1--(t) lig I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: WDate of Disposition 1 2/1 2/1 6 Place of Disposition pine. View Cemetery Queencbury, NY W (aaifess U) Horicon 38A & 39D, 4 (section) (lot number) (grave number) pName of Sex n or Person in Charge of Premis Connie L. Goedert ILI Z f (please print) Signature Title Cemetery Superintendet (over) DOH-1555(02/2004)