Howard, Fonda NEW YORK STATE DEPARTMENT OF HEAeTH - 4 It tvoq
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Fonda K Howard Female
Date of Death Age j If Veteran of U.S. Armed Forces,
September 10, 2012 70 War or Dates
1.. Place of Death Hospital, Institution or
Z City, Town or Village Lake George Street Address 58 Kings Rd.
Au Manner of Death tZl Natural Cause Accident n Homicide Suicide Undetermined Pending
ILIY"� Circumstances Investigation
w Medical Certifier Name Title
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Address
10 2 pc,s--.L. .5 , 'c (H),,.g TQ.Y ( D)
Death Certificate Filed District Number Register Number pv
City, Town or Village Lake George,NY 5651 0
❑Burial Date Cemetery or Crematory
❑Entombment September 12, 2012 Pine View Crematorium
Address
❑x Cremation 21 Quaker Road, Queensbury,NY 12804
Date I Place Removed
ZO n Removal 1 and/or Held
and/or Address
H Hold
N
O Date Point of
N n Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan & Denny Stafford 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
Ce
- Permission is hereby granted to dispose of the human emains described above as in icated.
Date Issued Ql/31/2, Registrar of Vital Statistics �d , nrn�A,--___
' (signature)
District Number 5651 Place Lake George,NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z u.l Date of Disposition 1-(i.(-it, n Place of Disposition uo,.., C•/'
w'briu,,
W (address)
Cl)
IY (section) Ai
(lot number) (grave number)
QName of Sexton or Person in Charge of Premises '+IK
Z (please print)
W Signature L Title Gllt Mici-Og,
(over)
DOH-1555(02/2004)