Lavaute, Virginia NEW YORK STATE DEPARTMENT OF HEALTH 30
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Virginia E. Lavaute Female
Date of Death Age If Veteran of U.S. Armed Forces,
June 28 2012 90 War or Dates
.. Place of Death Hospital, Institution or
ZCity, Town or Village Glens Falls Street Address Glens Falls Hos ital
11. Manner of Death I�I Natural Cause 1 I Accident ( I Homicide Suicide n Undetermined 1 Pending
.kijCircumstances Investigation
Medical Certifier Name Title
i
Address
C Death Certificate Filed District Number R t umber
z City, Town or Village Glens Falls,NY 5601 8
❑Burial Date Cemetery or Crematory
❑Entombment June 29,2012 Pine View Crematory
Address
®Cremation Quaker Road, Queensbury,NY 12804
Date Place Removed
Z n Removal and/or Held
C and/or Address
H Hold
N
a Date Point of
n Transportation Shipment
'p by Common Destination
Carrier
n Disinterment Date Cemetery Address
Reinterment Date Cemetery Address .
Permit Issued to Registration Number
=. Name of Funeral Home Regan & Denny Funeral Home 01444
Address
`. 94 Saratoga Avenue, South Glens Falls,NY 12803
Name of Funeral Firm Making Disposition or to Whom
! Remains are Shipped, If Other than Above
,S Address
tti
t>r. Permission is hereby granted to dispose of the human remains descri ed abov as !Zed.
ted.
Date Issued �(o� �/�- Registrar of Vital Statistics � ` ,.�
(signature)
`: District Number 56,01 Place Glens Falls,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z //'�
LuDate of Disposition 4lte (17. Place of Disposition F,w0yw (.rv►40c14.—
Ill (address)
N
0 (section) AJ (lot number) (grave number)
p Name of Sexton or Person in Charge of Premises (I tct1J4 r Sc,
WO
Z 1
(please print)
W Signature 41-t— Title Citriv4 4 dPL
(over)
DOH-1555(02/2004)