LaPoint, Deborah NEW YORK STATE DEPARTMENT OF HEALTH I, 4 503
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Deborah May LaPoint Female
Date of Death Age If Veteran of U.S. Armed Forces,
September 19, 2012 53 War or Dates
IPlace of Death Hospital, Institution or
W City, Town or Village Hartford Street Address
III
Manner of Death 0 Natural Cause El Accident El Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
W Medical Certifier Name Title
W
Thomas F Kandora, M.D .
Address
7240 Upper Broadway Fort Edward, NY 12828
Death Certificate Filed District Number Register Number
City,(fd�in or Village ( L- "- 6.-,.) .y 7 3 C/
0 Burial Date Cemetery or Crematory
September 26, 2012 Pine View Crematorium
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
0.�___I and/or and/or Held
� Hold Address
0 Date Point of
cI❑Transportation Shipment
(1) by Common Destination
,.-
0 Carrier
Date Cemetery Address
III Disinterment
Date Cemetery Address
❑ Reinterment
Permit Issued to Registration Number
Name of Funeral Home Carleton Funeral Home, Inc. 00281
Address
Carleton Funeral Home, Inc. 68 Main St., P. O. Box 67 Hudson Falls, NY 12839
Name of Funeral Firm Making Disposition or to Whom
t Remains are Shipped, If Other than Above
2, Address
Ili
1\
0- Permission is her by ranted to dispose of the human rema ns escr& ab ated. kiwi_
Date IssuedI.-L.-Registrar of Vital Statistics
(signature) 1
District Number 5 iSi Place 4(
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
al Date of Disposition h(Zg lit Place of Disposition F61,Vi.,) 6",-fo r+s---.
(address)
W
ce (section) (lot number (grave number)
p, Name of Sexton or Pers in Charge of/
'remises /,, t ' P
'
z `` (please print)
W Signature 1s---. .! Title <4fl4-TOt
(over)
DOH-1555 (02/2004)