Allen, Carol ,
NEW YORK STATE DEPARTMENT OF HEATH
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Vital Records Section Burial - Transit Permit
Name Firsarol Middle L. Laten Sex Female
Date of Death Age If Veteran of U.S. Armed Forces,
10/20/2016 56 years War or Dates
I- Place of Death Hospital, Institution or
Zown or AtYAW Wilton Street Address 276 Pyramid Pines Estates
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Manner of Death Natural Cause ❑Accident ❑Homicide ❑Suicide ri❑Undetermined El Pending
ILI Circumstances Investigation
ig Medical Certifier Name Title
p Christopher Mason M.d.
Adc1C51±iruyn Pavillion, Glens Falls, New York 12801
�Certifica� �d District Number Re ister Number
own or Wilton 4569•
❑Burial Date Cemetery or Crematory
10/21/2016 Pine View Crematory
s` ❑Entombment Addre
igl[ Cremation uueensbury, New York
Date Place Removed
Z Removal and/or Held
❑and/or
F Address
VA
Hold
0 Date Point of
t El Transportation Shipment
G5 by Common Destination
Carrier
❑Disinterment Date Cemetery Address
•
❑Reinterment Date Cemetery Address
Permit Issued to Densmore Funeral Home Reg rati�n Number
Name of Funeral Home
Address Sherman Avenue, Corinth, Ny 12822
iii Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
CC
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Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 10/21/2016 Registrar of Vital Statistics cut t, g
(signature)
District Number 4569 Place Wilton
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
III Date of Disposition JD/-i 116 Place of Disposition f r L Cl' v ifp.A ...
2 (address)
LU
CA
CC (section) //(lot number) (grave number)
Name of Sexton or Person in Charge f Premises !�/ > �S t^���
zu (ple se print)
Signature Title
(over)
DOH-1555 (02/2004)