Soifer, Regina NEW YORK STATE DEPARTMENT OF HEALTH .__ 's # 77
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Regina Nijole Soifer F
Date of Death 01 /1 1 /2 01 5 7 0 Age If Veteran of U.S. Armed Forces,
War or Dates
Place of Death Hospital, Institution or
City, Town or Village Lake George Street Address 6 Carriage Hill Road
Manner of Death ci Natural Cause 0 Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending
=_= Circumstances Investigation
Medical Certifier Name Title
Gary Scidmore Ph_C
4',1
Address 1340State Route 9, Lake George,NY 12845
Death Certificate Filed District Number Register Number
City, Town or Village Lake George
:❑Burial Date 01 /1 5/2 01 5 Cemetery or Crematory y
Pineview Cremator
❑Entombment Address
[ Cremation 21 Quaker Road, Queensbury,NY 12804
Date Place Removed
❑ Removal and/or Held
and/or Address
Hold
, „ Date Point of
❑Transportation Shipment
by Common Destination
Carrier
Date Cemetery Address
❑ Disinterment
❑ Reinterment
Date Cemetery Address
�` Permit Issued to Registration Number
Densmore Funeral Home 00448
Name of Funeral Home
.- - Address
7 Sherman Ave, Corinth,NY 12822
4
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
�l a;
t,¢` Permission is hereby granted to dispose of the human remains escribed .bove as indicated.
Date Issued /—lL— /S g
Re istrar of Vital Statistics (C.. ' /
(sigma re)
I District Number `j 1 S 1 Place ',Q (V..-n ;
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition i/1 y I is Place of Disposition Ziv tk 6+0c140..-
(address)
, (section) �+ _ (lot number) (grave number)
Name of Sexton or Person in Charge of Premises +�
(please print)
Signature 'mil4 Title c
(over)
DOH-1555 (02/2004)