Larrivee, Jeanne NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Jeanne L. Larrivee Female
Date of Death Age If Veteran of U.S.Armed Forces,
12/14/2015 79 War or Dates
i- Place of Death Hospital, Institution or
W )Olt,,Town otXJXIit X Queensbury Street Address 24 Pine Street
p Manner of Death®Natural Cause 0 Accident 0 Homicide 0 Suicide Undetermined Pending
W Circumstances Investigation
W Medical Certifier Name Title
0 Robert Sponzo M.D.
Address
Cancer Center 102 Park St. Glens Falls N.Y. 12801
Death Certificate Filed DisWEt Number Register umber
43/) ,Town dtAilfil31 Queensbury J j
i:rial Date Cemetery or Crematory
12/15/2015 Pineview Crematorium
tombment Address
emation 21 Quaker Road Queensbury N.Y. 12804
Date Place Removed
Z Removal and/or Held
C and/or Address
N Hold
O Date Point of
a❑Transportation Shipment •
Cii by Common Destination •
Carrier
Q Disinterment Date Cemetery Address
` [�Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Radloff Funeral Home Inc. 1425
`Y' Address
' 136 Warren Glens Falls N.Y. 12801
Name of Funeral Firm Making Disposition or to Whom
h Remains are Shipped,If Other than Above
Address
re
Permission is hereby ranted to dispose of the human mains described above as indicated.
Date Issued La I l c i Registrar of Vital Statistics Q. A
__r
(signature)
District Numberc(0 c Place I 0 u-
y-\ 0( ()
HI certify that the remains of the decedent identified above were disposed of in accor ance with his permit on:
Date of Disposition /2-15'-/t Place of Disposition P,iAe U r e„) L re r1� o
W (address)
CD
cc (section)i / (lot number) (grave number)
pName of Sexton P o in Charge of Premises k 1 i�-n C�4 '-el-e
Z (please print)
Ili Signature '�. Title C/'e,./47o ‹.Ssf sj4,.74----
(over)
DOH-1555(02/2004)