LaFontaine, Ernestine Sy
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle 1 i Last i Sex
Ernestine LaFontaine Female
Date of Death Age If Veteran of U.S. Armed Forces,
January 24, 2012 92 War or Dates
, Place of Death Hospital, Institution or
Z City, Town or Village Queensbury I Street Address Westmount Health Facility
aManner of Death j Natural Cause Accident Homicide Suicide Undetermined Pending
W Circumstances Investigation
w Medical Certifier Name I Title
A estipil g
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Death Certificate Filed District Number Register Number
City, Town or Village Queensbury I 5671 /1,5
❑Burial Date Cemetery or Crematory
January 27, 2012 1 Pine View Crematorium
❑Entombment Address
III Cremation 21 Quaker Road, Queensbury,NY 12804
Date Place Removed
Z Removal and/or Held
and/or Address
H Hold
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0 Date Point of
cnTransportation 1 i Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
I
=` Permit Issued to Registration Number
Name of Funeral Home Regan & Denny Funeral Home 01443
Address
53 Quaker Road, Queensbury, NY 12804
Name of Funeral Firm Making Disposition or to Whom
i- Remains are Shipped, If Other than Above
2 Address
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,, Permission is hereby granted to dispose of the human r mains d scribedJJ
abov as indicated.
Date Issued /-,;?.c,,-�ul Z- Registrar of Vital Statistics ____--_______
(signature)
District Number 5671 Place Queensbury
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z
W Date of Disposition j•-af,-,a4)(2__ Place of Disposition ire 0 e (re on&Aor v4,1
M (address)
W
co
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(section (yot number) (grave number)
pName of Sexton or Person in Charge of Premises 1 ,m0- ) 8`v tie(le
W '�. �'�a..�r /A Y (please print)
Signature ` .,� Title C«vncc,4 ,ry A554 .
(over)
DOH-1555(02/2004)