Boucher, Lois /f ?f(o
NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial - Transit Permit
:::., Name First Middle Last Sex
Lois H. Boucher Female
:::r Date of Death Age If Veteran of U.S. Armed Forces,
r: April 13, 2015 100 War or Dates
i:.::
Place of Death Hospital, Institution or
City, Town or Village Ft. Edward Street Address Fort Hudson Nursing Home
Manner of Death I XI Natural Cause Accident I I Homicide Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Kti Daniel Larson
Address
9 Carey Road,Queeensbury,NY 12804
::':' Death Certificate Filed District Number Regis r umber
•:%:. City, Town or Village Fort Edward 5755
❑Burial Date Cemetery or Crematory
April 17, 2015 Pine View Crematory
Entombment Address
El Cremation Quaker Road, Queensbury, NY 12804
Date Place Removed
ZZ I I Removal and/or Held
and/or Address
,1"- Hold
Cl)
O Date Point of
O.
Transportation Shipment
p by Common Destination
Carrier
Disinterment Date Cemetery Address
17 Reinterment
Date Cemetery Address
j:;: Permit Issued to Registration Number
V:: Name of Funeral Home Regan Denny Stafford Funeral Home 01443
ll
Address
.L 53 Quaker Road, Queensbury,NY 12804
▪ Name of Funeral Firm Making Disposition or to Whom
I• ` Remains are Shipped, If Other than Above
Address
:; Permission is ere y granted to dispose of the hu an ins describ ab ve as indicated.
▪ Date Issued 4 6 ( Registrar of Vital Statistic 11.1 . 1
rr;, (signature
District Number 5755 Place Fort Edward
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition q'Ionis- Place of Disposition gJ1L., 6-4.;"b,0,,,
2 (address)
W
N
CL (section) /ZoOt-
(lot num r) (grave number)
pName of Sexton or Person in Charge of Premises it ►-
Z t ( lease print)
w Signature �j. 4—. Title l4.10 714.
(over)
DOH-1555(02/2004)